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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # COMMENTS: SERVICE REQUEST#1 HOA PHONE # EXT' Burketts Pool Plastering ~ �� `T- OWNER / OPERATOR AQUI& FAz# 600 N Frontage Rd Village At Spanos West ( ) CITY Ripon CHECK If BILLING ADDRESS� FACILITY NAME '^ y�l,/y' Iry v�� EMPLOYEE#: DATE: Village At Spanos West EMPLOYEE #: DATE: Date Service Completed (If already completed): SITEADDRESS SERVICE CODE: C L— Fee Amount: -271D Amount Paid 43b4-- r Payment PaymDate l Q 2a I Mokelumne Cir S Stockton 95219 6226 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE zip PHONE#1 EzT' I ) APN # LAND USE APPLICATION # PHONE #2 EX . BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS Bryan Lawrence COMMENTS: BUSINESS NAME / yC D PHONE # EXT' Burketts Pool Plastering t;wr.T 12 209-624-2918 HOME Or MAILING ADDRESS AQUI& FAz# 600 N Frontage Rd NE4L�'gpMENTAC >Y ( ) CITY Ripon STATE CA Zip 95366 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 FEDERAL l ws. APPLICANT'S SIGNATURE: DATE: 10-22-20 PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER OTHERAUTHORIZEDAGENTEl Contractor If APPLiCANTisnotthe BYLL/NGPeeTr proof 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: \Z.em a.^,'✓� C�'LQ.E' COMMENTS: / yC D t;wr.T 12 AQUI& NE4L�'gpMENTAC >Y ACCEPTED BY: '^ y�l,/y' Iry v�� EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (If already completed): SERVICE CODE: C L— Fee Amount: -271D Amount Paid 43b4-- r Payment PaymDate l Q 2a Payment Type C Invoice# c# S Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003