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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> HOA 3 <br /> OWNER / OPERATOR <br /> North Point Villas CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> North Point Villas <br /> SITE ADDRESS Mill Springs Dr Stockton 95219 <br /> 3634 Street Number Direction 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 /> ( ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Hugo Varo CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Burketts Pool Plastering 209-624-2918 <br /> HOME or MAILING ADDRESS FAX # <br /> 600 N Frontage Rd ( ) <br /> CITY Ripon STATE CA ZIP 95366 <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, Standards, STATE and FEDERAL laws . <br /> 5/ 11 /21 <br /> APPLICANT ' S SIGNATURE : DATES <br /> PROPERTY / BUSINESS OWNER ElOPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT El Contractor <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 : a12 I r !AM <br /> COMMENTS : <br /> h N��qQ�/N �®2� <br /> E9GTy��q��CO444 <br /> ACCEPTED BY : I EMPLOYEE # : DATE : f Z <br /> ASSIGNED TO : V ` EMPLOYEE # : 1 DATE: /12 2 <br /> Date Service Completed (if already completed) : SERVICE CODE: s, P <br /> Fee Amount "�) Amount Pail /5047 SOD Payment Date <br /> Payment Type CR jt Invoice # Check # 12 `523�(p Z Receive6 By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />