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San Joaquin County Environmental Health Department Owner / Operator Hope Ministries, Inc. Facility Name 95337 Zip Code Street Number Manteca apn # Ext.BOS District Location Code CONTRACTOR / SERVICE REQUESTOR Requestor Bob Raymus Business Name Ext.Raymus Construction, Inc.470-1093 ) City Manteca Zip 95336 1/18/2024 Construction Administrator Type of Service Requested: Comments: Accepted By:Employee#:Date: Assigned to:Employee#: Service Code:I IfO I Fee Amount: Payment Type Invoice # SR FORM (Golden Rod) BILLINC. 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 laws. Type of Business or Property Non profit community center ________________ Date: Other Authorized Agent [3 Manteca ___________City Yosemite Avenue ________________Street Name East Direction IWXMCl It'HJKdTW Operator / Manager D Phone #1 ExT- ( ) 209-470-1093 Bob Raymus Phone#2 () SERVICE REQUEST FACILITY ID # _________________Street Name______ State Zip CA 95336 Land Use Application # Vc-clv vvyy______________ Date Service Completed (if Already completed): Check if Billing Address O Home or Mailing Address 1433 Moffat Blvd. Suite 13 SERVICE REQUEST# Check if Billing Address O ,________ SZ3 Amount Paid Payment Date [Check# HSogO?// EHD 48-02-025 „ REVISED 11/17/2003^0^-4 „ P/E: w Received By: Thomas Toy Community Center Site Address 602____________Street Number Home or Mailing Address (If Different from Site Address) P.O. Box 4088 City /-/2f^ APPLICANT’S SIGNATURE: Brenda Geringer Property / Business Owner IJ Applicant is not the Billing Party, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1. 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 availableft^<y»h^^,ime time it is provided to me or my representative. D r- '•It ld^ Z /VfclQ' , JAN19 2O24 SaF\J jq a _x, Fax# _____(_ STATE CA