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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property o n (:! FACILITY ID # SERVICE REQUEST # BUSINESS NAME f%�� PHONE # EXT. Dillon & Murphy Engineering OWNER / OPERATOR HOME or MAILING ADDRESS sA 2022 ry JOA FAX# o b i a PartnersInc,c e rothers CHECK if BILLING ADDRESS 0 FACILITY NAME EMPLOYEE #: DATE: L . SITE ADDRESS 18846 St. Rt. 99 E. Frontage Rd. ASSIGNED TO: FK Ac 95220 Street NumberEDc Date Service Completed (if already Completed): to SERVICE CODE: J J Stree Name Fee Amount: h0 city Ci i Cod HOME or MAILING ADDRESS (If Different from Site Address) 11 9 Involce # E. Weber Ave. Check # /L Received By: Street Number Street ."-- CITY Stockton STATE Zip 95202 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 986-4150 017-090-51 PHONE #T EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR o n (:! Josh McBride CHECK if BILLING ADDRESS Er BUSINESS NAME f%�� PHONE # EXT. Dillon & Murphy Engineering 209 334-6613 HOME or MAILING ADDRESS sA 2022 ry JOA FAX# P.O. Box 2180 010 ( ) CITY Lodi STATE CA Z'P 95241 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator, or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTTI DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE d FIS l� , la APPLICANT'S SIGNATURE: DATE: 03/04/2022 PROPF,RTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® Engineer IfAPPTIC'ANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or Operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTII DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: o n (:! PA COMMENTS: f%�� sA 2022 ry JOA 010 yE9lTy 01yM N�UAITY ACCEPTED BY: ��`' EMPLOYEE #: DATE: L . ASSIGNED TO: FK EMPLOYEE #: DATE: L) f.' Date Service Completed (if already Completed): SERVICE CODE: J J P / E: j J � Fee Amount: h0 Amount Paid / I Payment Date Payment Type Involce # Check # /L Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003