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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # HOME or MAILING ADDRESS PO Box 2180 -c20-(h FAx# ( ) 334-0723 CITY Lodi STATE CA ZIP 95241 522 OWNER / OPERATOR CHECK Servillano Hortizuela if BILLINGADDRESSE] FACILITY NAME ENVIRONMENTAL ACCEPTED BY: �� ' SITE ADDRESS S 39-7 I Hildreth Lane Stockton T- 95212 Street Number Direction Street Name S 3 Ci Fee Amount: Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 3172 Enqlish Oak Circle Street Number Street Name CITY Stockton STATE CA zip 95209 PHONE #1 EXT. ( 209) 612-7417 APN # 1 085-230-07 LAND USE APPLICATION # PA -2100215 PHONE #2 EXT. BOS DISTRICT LOCATIJ CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Mike Toy CHECK if BILLING ADDRESS BUSINESS NAME Dillon & Murphy PHONE# EXT. 334-6613 HOME or MAILING ADDRESS PO Box 2180 -c20-(h FAx# ( ) 334-0723 CITY Lodi STATE CA ZIP 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 HEALTH 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 and FEDERAL laws. APPLICANT'S SIGNATURE: _ /' , _ • -- DATE: 7 /7i Z17i7/ ...._— c:. (- PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER 11 OTHER AUTHORIZED AGENT ❑ If APPLICANT 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: RECEIVED MAY 0 3 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL ACCEPTED BY: �� ' EMPLOYEE #: DATE: �:- 3 d ASSIGNED TO: FY L1 N / EMPLOYEE #: DATE: 5 3 a Date Service Completed (if already completed): SERVICE CODE: S 3 P I E: a 6 Fee Amount: Amount Pa% 0E. on Payment Date S3 Zz_ I Payment Type Invoice # Check # 203 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003