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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS 0 SERVICE REQUEST # COMMENTS: # En. � (2 l OWNER/ OPERATOR 599-3317 HOME or MAILING ADDRESS DFp" IV '9R7� CHECK If BILLING ADDRESS FACILITY NAME Summergate HOA 600 N. Frontage Rd. ACCEPTED BY: SITE ADDRESS 998 W Grantline Rd. STATE CA Tracy 95376 Street Number Direction Street Name SERVICE CODE: rl 7 city i Zip Code HOME or MAILING ADDRESS (If Different from Site Address) -P, O D� Payment Date Street Number Check #Recei Street Name CITY STATE ZIP PHONE#1 En. ( ) APN# LAND USE APPLICATION# PHONE #2 En. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS 0 BUSINESS NAMEPHONE COMMENTS: # En. Burkett's Pool Plastering 209 599-3317 HOME or MAILING ADDRESS DFp" IV '9R7� FAX# 600 N. Frontage Rd. ACCEPTED BY: CITY Ripon STATE CA ZIP 95366 BILLING 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 APPLICANT'S SIGNATURE: i5tkan, I I a tt m DATE: 12/18/2018 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® Draftsman IfAPPLICANT i5 nol the BILLING PAR%Y proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 essment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sa[p1D.�j is provided to me or my representative. R • ry,�p,r TYPE OF SERVICE REQUESTED: 0 EHD 48-02-025CMO SR FORM (Golden Rod) REVISED 11/17/2003 COMMENTS: 10 H�eWio'�oo/ DFp" IV '9R7� NT ACCEPTED BY: EMPLOYEE #: DATE: '2 2 �I ASSIGNED TO: EMPLOYEE #: 'Z DATE: , Date Service Comp ted (if already Completed): SERVICE CODE: rl 7 i Fee Amount: Amount Pal -P, O D� Payment Date Payment Type s Invoice # Check #Recei d By: EHD 48-02-025CMO SR FORM (Golden Rod) REVISED 11/17/2003