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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propertyrrll FACILITY ID # SERVICE REQUUEST # <br /> HOA Vu q/ /0) /00? 60 9 54 <br /> OWNER / OPERATOR <br /> Vista Verde Apts CHECK If BILLING ADDRESS <br /> FACILITY NAME Vista Verde Apts <br /> SITE ADDRESS Stonewood Ave Manteca 95336 <br /> 1405 Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #t ExT. APN # LAND USE APPLICATION # <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 /> APPLICANT ' S SIGNATURE : 3/29/2021 <br /> DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® 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/siitlfei <br /> t/e �allsse s nt <br /> il <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at M, is <br /> provided to me or my representative . RECEIVED <br /> TYPE OF SERVICE REQUESTED : , <br /> COMMENTS : MAR <br /> 4 9021 <br /> SAJOAQUIN ENVIRONMENTAL <br /> HEALTH DEPARTME T <br /> ACCEPTED BY: EMPLOYEE # ::W ( DATE: <br /> ASSIGNED TO : EMPLOYEE # : DATE : •!��// <br /> Date Service Completed (if already completed) : SERVICE CODE: P / E : I O <br /> Fee Amount : O U TAmount Paid 3 O _ Payment Date 3 � Lp v <br /> Payment Type VL, Invoice # C kZZ Z Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />