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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ,l SERVICE REQUEST# <br /> Single Family Residence <br /> OWNER/OPERATOR <br /> Bryan Valencia CHECK If BILLING ADDRESS 1-3 <br /> FACILITY NAME <br /> SITE ADDRESS 19 155E p-Read and Allen Road Ripon 95366 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 456-6538 1245-070-81 <br /> PHONE#2 EXT_ BOS DISTRICT7-71 LOCATION CODE <br /> ( ) 004 OS <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Bryan Valencia CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> (209) 456-6538 <br /> HOME or MAILING ADDRESS FAx <br /> 2406 Olive Grove Ct. ( ) <br /> CITY Riverbank STATE CA ZIP 95367 <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,ST E nd FEDERAL laws. / l ' <br /> APPLICANT'S SIGNATURE: DATE: Io/Zy <br /> PROPERTY/BUSINESS OWNER OPERATOR/OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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. QP <br /> TYPE OF SERVICE REQUESTED:Plan Check Review <br /> COMMENTS: Oct �® <br /> awdo Zs 2418 <br /> H�cry�qC A N'Y <br /> .gRTM�NP <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: liAlwo <br /> EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5523 P i E:4201 <br /> Fee Amount: $304 Amount Pai 3640 Payment Date ;S <br /> Payment Type Invoice# Check# 0-71 eceiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> J <br />