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2 <br /> 00 n 199 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL ALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> McCarthy, Richard A. &Tina M. <br /> FACILITY NAME <br /> SITEADDRESS 21718 N Cord Road Clements 95227 <br /> Street Number I Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 279 Street Number Street Name <br /> CITY STATE ZIP <br /> Clements CA 95227-0279 <br /> PHONE#1 E)cT• APN# LAND USE APPLICATION# <br /> (209 )765-7238 1023-200-050 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Richard McCarthy CHECK if BILLING ADDRESSO <br /> BUSINESS NAME PHONE# E)cr• <br /> 209 765-7238 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 279 ( ) <br /> CITY Clements STATE CA Zip 95227-0279 <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,Standar and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:—"112120 <br /> PROPERTY/BUSINESS OWNER® OP OR/MANAGER❑ OTHER AUTHORIZED AGENT❑_ _ <br /> IfAPPmcANT 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 same time it is <br /> provided to me or my representative. <br /> I <br /> TYPE OF SERVICE REQUESTED: S � <br /> COMMENTS: <br /> PA- Y-e� Pft <br /> ACCEPTED BY: / EMPLOYEE#: rjJ Qf�T I <br /> ASSIGNED TO: � y��_ +l EMPLOYEE#: ��� (^�J0 <br /> Date Service Completed (if already completed): SERVICE CODE: �7 2 c: 3 <br /> Fee Amount: "/ Amount Paid OO Payment Date C ft( 2m <br /> Payment Type �1 /`' Invoice# �( �j Received By: <br /> C� r <br /> V <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />