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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L 'D�)' `� 2. <br /> OWNER/OPERATOR Brent Honnoll <br /> CHECK If BILLING ADDRESS D <br /> FACILITY NAME <br /> SITE ADDRESS33503 S Koster Rd Tracy�/ 95304 <br /> Street Number Direction Street Name C' ZJp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> same as above Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> ( ) 209-740-8387 T255-090-320 <br /> PHONE#2 ExT. BOS DISTRICT ` LOCATION CODE, <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Robert Smith Email: ccps.rls@gmail.com <br /> BUSINESS NAME PHONE# Err. <br /> 916-229-2424 <br /> HOME or MAILING ADDRESS FAx# <br /> PO BOX 22748 ( ) <br /> CITY Sacramento STATE Ca ZIP 95822 <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 ENviR0NMENTAL 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 ap lifation_and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Staizdards, STATE and_-EDERAL laws. <br /> APPLICANT'S SIGNATURE:, DATE: <br /> _ - — t ' <br /> PROPERTY/BUSINESS OWNER L 1 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 same time it is <br /> provided to me or my representative. 1 <br /> TYPE OF SERVICE REQUESTED: I sl i; }C%t�j i I ri a rlf 4I }YG1�e Lc, -J)r%ta S u C/, <br /> COMMENTS: <br /> kecety-eo v)u ewc4 F�� ��t�c/fcJ t� ;nsPrt ter SEP <br /> SAN <br /> 'JOA 2 8 ?021 <br /> t QU <br /> PA R <br /> ACCEPTED BY: .l EMPLOYEE#-. :_"�r i-r DATE: <br /> ASSIGNED TO: S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: s�� P/E: a(�v <br /> Fee Amount: r��j > Amount Pal (Q 6,y Payment Date �$ <br /> Payment Type V Invoice# Check# 3� �' I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />