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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Tristan Hartung REQUEST # Residential EMPLOYEE #: PHONE # EXT. /SERVICE a �1 OWNER/ OPERATOR 209 334-6613 McCarthy, Rlchrd A. & Tina M. CHECK If BILLING ADDRESS FACILITY NAME PO Box 2180 SITE ADDRESS N Cord Road STATE CA ZIP 95241 Clements 95227 21718 Street Number Direction Street Name Received By: city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) PO Box 279 Street Number Street Name CITY STATE ZIP Clements CA 95227-0279 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 765-7238 1023-200-050 PA -2000199 PHONE #2 EXT. BOS DISTRICT LOCATION CODE U CONTRACTOR / SERVICE REQUESTOR REQUESTOR COMMENTS: Tristan Hartung CHECK if BILLING ADDRESS BUSINESS NAME EMPLOYEE #: PHONE # EXT. Dillon & Murphy EMPLOYEE #: 209 334-6613 HOME or MAILING ADDRESS FAX # PO Box 2180 P i E: 61 o� ( ) CITY Lodi STATE CA ZIP 95241 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and EDEA laws. APPLICANT'S SIGNATURE: DATE: '2 JvCJ ZCZ I PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGE OTHER AUTHORIZED AGENT Staff If APPLICANT is not the BILLING PARTY, prddf of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: s J l I} G, 6! t Jy lqt'7d /v i rU 100 O I P' S }Udy e ,�?'#XM E NT COMMENTS: JUN 2 9 202 SAN JOAQUIN COU ENVIRONMENTAL HEALTH DEPARTME ACCEPTED BY: roT�� /— EMPLOYEE #: DATE: b '9 G a J ASSIGNED TO: }. EMPLOYEE #: DATE: (� ,;? d Date Service Completed (if already completed): SERVICE CODE: P i E: 61 o� Fee Amountg : Amount Paid _ Payment Date Payment Type Invoice # Check # Z Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 FIR VT