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SAN JOAQUIN♦AUNTY ENVIRONMENTAL HEALTH T ..ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> IcAz WWI 3W <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Stonegate Apts. <br /> SITE ADDRESS VV Center St. Manteca 95337 <br /> 1451 Street Number Direction Street Name city Zip Cede <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 /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> Burkett's Pool Plastering 209 599-3317 <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 /> APPLICANT'S SIGNATURE: (�Lft A IL / I Lt.O"IL DATE: 11/29/2018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Draftsman <br /> IfAPPL1CANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Atime it is <br /> provided to me or my representative. /y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 3 0 <br /> H47h 7!D,�pgQCOUo,4- <br /> qk <br /> TMENT <br /> ACCEPTED BY: EMPLOYEE M 3 DATE: y/ <br /> If <br /> ASSIGNED TO: EMPLOYEE#: Gs( l <br /> DATE: !t <br /> Date Service Compl ed (if already completed): SERVICE CODE: 523 PIED <br /> Fee Amount: rfb db Amount Paid-1 , o4�b Payment Date ft <br /> nvoice# Check# Lfti <br /> S57tf'7 <br /> Payment Type 7'S,— IReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />