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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Senior Center <br /> OWNER/OPERATOR City of Manteca <br /> CHECK If BILLING ADDRESS <br /> FACILITYNAME Manteca Senior Center <br /> SITE ADDRESS 295 Cherry Lane Manteca 95337 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1001 West Center Street <br /> Street Number Street Name <br /> CITY Manteca STATE CA zIP 95336 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (209) 456-8615 216-03-003 <br /> PHONE#2 Err. BIDS DISTRICT LOCATION CODE <br /> (209) 456-8600 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 FEUERIs . <br /> APPLICANT'S SIGNATURE: � DATE: 3/30/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT Park Planningand Project Superintendent <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 thsame time it is <br /> provided to me or my representative. Q <br /> TYPE OF SERVICE REQUESTED: Plan review CF <br /> COMMENTS: M,IpM/f <br /> 30 <br /> SANS 2021 <br /> NEgLTH p pa,r7 4t <br /> EAtr <br /> ACCEPTED BY: Vidal PedraZa EMPLOYEE#: 6213 DATE: 3-30-21 <br /> ASSIGNEDTO: Vidal PedraZa EMPLOYEEM 6213 DATE: 3-30-21 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 P/E 1601 <br /> Fee Amount: 456 Amount Paid On I <br /> Payment Date cyzp ,P-/ <br /> Payment Type /S L— Invoice# Check# Zzq`f6G 3 Rec ed By: <br /> EHD 48-02-025 Payment confirmation# 122946637ORM(Golden Rod) <br /> REVISED 11/17/2003 31,E �[�Q Q(�,(��/(CA7 <br />