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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />COMMENTS: <br />ACCEPTED BY: r G <br />OWNER/OPERATOR DALE MUNSCH <br />EMPLOYEE M <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS 16133 <br />I <br />MOORE ROAD <br />Date Service Completed (if already completed): <br />LODI <br />95242 <br />Street Number <br />Direction <br />Street Name <br />(��O• dV <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Check # 3 <br />250 Street Number <br />Received By: <br />c <br />CROSS STPZ" <br />CITY LODI CA 95242 <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 712 6069 <br />027-020-16 <br />PHONE#2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR TAMARA WOODS <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESSNAME TERRACON CONSULTANTS INC. PHONE# EXT. <br />209)367-3701 bb <br />HOME or MAILING ADDRESS 902 INDUSTRIAL WAY FAx# . fl.._ ` jP <br />CIT'/ LODI, CA 95240 <br />STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autho Jagent df , 114, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associ t (y} s„projeCct <br />or activity will be billed to me or my business as identified on this form. E,q�TH p�pq�F,��PllT77q� � <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAID JRN <br />COUNTY Ordinance Codes, Standards, STAT and Aand/FERAL laws. <br />APPLICANT'S SIGNATURE: LTA/� DATE: ��/Z2, <br />PROPERTY/ BUSINESS OWNER 10 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: y' 1 S v ; I{ G, I 1 L:r <br />pl I �J , r /Li C' <br />( J YI S)U(Av - <br />COMMENTS: <br />ACCEPTED BY: r G <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: t\I <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: S <br />P 1 E: <br />Fee Amount: <br />Amount Pai <br />(��O• dV <br />Payment Date ZZ_ <br />Payment Type 1�1 <br />Invoice # <br />Check # 3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />