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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential APN 208-20-015 '�Ro N q <br /> OWNER/OPERATOR <br /> Jose Valdovinos CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Enriquez Residence <br /> SITE ADDRESS 17650 Austin Road Manteca 95336 <br /> Street Number I Direction Street Name cjtv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 733 Shadowbrook Lane <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Manteca CA 95336 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION NO.: <br /> (209 ) 628-0986 208-20-015 <br /> PHONE#2 EXT_ BOS DISTRICTLOCATION CODE <br /> 4 <br /> ( ) G t!, <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Jose Valdovinos, Contractor CHECK If BILLING ADDRESSO <br /> BUSINESS NAME n/a PHONE# EXT. <br /> 209 628-0986 <br /> HOME or MAILING ADDRESS FAX# <br /> 733 Shadowbrook Lane ( ) <br /> CITY Manteca STATE CA ZIP 95336 <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: h DATE: 04/06/2022 <br /> PROPERTY/BUSINESS OWNER® PER4T /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s1AAtlrTleitiY��NT <br /> provided to me or my representative. / <br /> TYPE OF SERVICE REQUESTED: S�;I �,;I cj i I1 t " 6i Nd N 7'f,,1 fe LDC4('J1'1 { U<.., C v Y*.l <br /> Kr—CLIV=D <br /> COMMENTS: SSN LS ys'-15 P.aM�+I�K'n APR 1+ 22 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMEN rAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �� L= EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: Lf /3/ .1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid o Payment Date 13 LU L <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />