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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />"lct CocA I <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FAcIUTY NAME Waterstone Apartments <br />SITE ADDRESS <br />1951 Street Number Direction Middlefield Dr. Street Name Tracy <br />Cltv <br />95377 Zlo Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street. Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Err. APN # LAND USE APPLICATION # <br />PHONE #2 Err. PHONE <br />( ) <br />BOS DISTRICT <br />D3 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Burkett's Pool Plastering <br />PHONE # <br />(209 ) 599-3317 <br />Exr. <br />HOME or MAILING ADDRESS <br />600 N. Frontage Rd. <br />FAX # <br />( 1 <br />Cur 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: 111a4-c-n, DATE: 9/19/2018 <br /> <br />PROPERTY / BUSLNESS OWNER!!! OPERATOR / MANAGER 0 OTHER AUTDORIZED AGENT In Draftsman <br />ijAPPLICAN7' 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, geotecb_nical data and/or environmental/tip assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as S0011 as it is available and at thedi <br />provided to me or my representative, <br />TYPE OF SERVICE REQUESTED: ()643,( <br />....ivel pc,44,144Lx. SEP 2 R <br />COMMENTS: <br />u 20/8 SAN JOil <br />kle,ILIZTONAIEN UNrk <br />DEFivii r rAt. moa. <br />I ACCEPTED BY: i EMPLOYEE #: le 2,4 3 DATE: <br />ASSIGNED TO: EMPLOYEE #: <br />i <br />42 /1 ; e) <br />AA <br />DATE: e 2.i g <br />Date Service Co pleted (if alr dy completed): SERVICE CODE: 5-P/ : 30942..... <br />Fee Amount: , Amount Paid #3(y./. OO Payment Date <br />Payment Type 14... Invoice # Ch)36# 6,,V4z4f3z ,./037 3 Received By: <br />• <br />is <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003