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X200 <br /> SAN JOAQUIN —OUNTY ENVIRONMENTAL HEALTH Lr.PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential 5R 00 8(o O? g <br /> OWNER/OPERATOR <br /> Fernado Rico CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 15 N Olive Avneue Stockton <br /> 95215 <br /> Street Number I Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4615 E. Third Street <br /> Street Number Street Name <br /> CITY Stockton STATE CA ZIP 95215 <br /> PHONE#t EXT• APN# LAND USE APPLICATION# <br /> (209 ) 915-1359 157-210-46 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Cesar Palacios CHECK if BILLING ADDRESS <br /> BUSINESS NAME Dillon & Murphy PHONE# 334-6613 EXT. <br /> 209 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 2180 <br /> ( ) <br /> CITY Lodi STATE CA ZIP 95241 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 <br /> COUNTY Ordinance Codes,Standards,STATE and F RAL Iaws. <br /> APPLICANT'S SIGNATURE: DATE: /616/2-02-Z Ws��..N.r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY_proof of authorization to sign is required Title REe ED <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property d? h�0 <br /> 22 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thSANWAl=41 01JNTY <br /> provided to me or my representative. ENVIRONMENTAL <br /> MENT <br /> TYPE OF SERVICE REQUESTED: � �'� yojt� � .� (� �� <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: (�9 DATE: <br /> ASSIGNED TO: S (� EMPLOYEE#: DATE: <br /> Date Service Completed (if (ready completed): SERVICE CODE: P I E: Qj <br /> Fee Amount: I Amount Paid 3 — Payment Date (( oZ 22, <br /> Payment Type Invoice# Check# 2j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />