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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential <br /> OWNER/OPERATOR <br /> McCarthy, Richard A. &Tina M. <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 21718 NCord Road Clements 95227 <br /> Street Number Direction Street Name city 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 EXT. APN# LAND USE APPLICATION# <br /> (209 )765-7238 023-200-050 (7 l-f gq <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Richard McCarthy CHECKIfBILLINGADDRESSO <br /> BUSINESS NAME PHONE# EXT. <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: 1-11121z, <br /> PROPERTY/BUSINESS OWNER® OP OR/MANAGER ❑ OTHER AUTHOR[ZED 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: G J , <br /> COMMENTS: W,9 PA- <br /> y,-�- . P4 �p� <br /> ft6 <br /> ACCEPTED BY: EMPLOYEE#: \ NV/ I i4 4 <br /> ASSIGNED TO: i/VI EMPLOYEE#: CJ N �N <br /> Date Service Completed (if already completed): SERVICE CODE: Z,60-3- <br /> Fee Amount: Amount Paid �p Payment Date <br /> Payment Type Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />