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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Single Family Residence <br /> OWNER/OPERATOR <br /> Eric Nielsen CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Carrolton Road and Allen Road Ripon 95366 <br /> Street Number I Direction I 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) 303-5873 1245-070-60 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) 004 os <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Eric Nielsen CHECK If BILLING ADDRESS M <br /> BUSINESS NAME PHONE# ExT. <br /> (209) 303-5873 <br /> HOME or MAILING ADDRESS 4313 Lighthouse Avenue FAx# <br /> ( ) <br /> CITY Modesto STATE CA ZIP 95356 <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 on d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ,STATE EDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <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 <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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the sa e . It IS <br /> provided to me or my representative. / <br /> TYPE OF SERVICE REQUESTED:Plan Check Review <br /> COMMENTS: ®� <br /> SAN <br /> Fiy��AQUiN <br /> H��Ty�FpgR <br /> N <br /> ACCEPTED BY: 14 EMPLOYEE#: DATE: L4 I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 523 P E4201 <br /> Fee Amount: $304 Amount Pai 3114LO6 Payment Date �S ` <br /> Payment Type C Invoice# Check# /Q Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />