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02/23/2001 08:41 209468.'1433 FIFTH FLUOR PPICZE 05 <br />SER",ACE REQUEST <br />Type or &.54i ,3s or Pro perty FACILITY ID # SPICE /�R/c�QUE3T <br />MARINA N-483 00 2 r <br />OwtrQt►OPEP Tol <br />THE PEGASUS GROUP / VILLAGE WEST MARINAr l8twltc PAM <br />ar Y NAME <br />FAt: <br />VILLAGE WEST MARINA <br />6649 Shnlawre« hsneau, EMBARCADERO DRahh.ra.�, <br />Mailing ljddrey� pf <br />rent from Site Address) <br />Cary <br />PNot+e#1 Err. APNO <br />PHONfiI>2 Exr. BOS OasiRrr <br />SERVICE REflUESfOR <br />REouEsiax <br />STM ZIP <br />LA MUSEAMXAT1tMRB <br />!AnOIt. 6bF- <br />CLUNG Pruni ❑ <br />BUSINESS NAME <br />Pfroas# , 7— ar. <br />MawNr AntxtESs FAX# <br />271 5.37 -`73%1 <br />CITY SrA'M LP �5 317 <br />BILLING ACKNOWLUGEMENT: I, the und**ned property or business owner, OPMA49f of authorced agent of same, adnowtedge that al a% ander pMIW Spfta, <br />Ram I-Imm ftRA FS &WIR04wWTAL IiE&TH Div "thWfiY charges essoaetad with this project Gr aaIvhy M4 be Oiled m meariny business 23 Neil W d1 US tamL <br />I also certify that I have prepared ttd9 appUton and that the warts in ba peMarnred *11 be done in Oeoxdanoe WIM d$AN JMgUw CbtptlY ONfrtanae Callas. Standards STATE one <br />FEDEdAL lava. <br />i <br />Arfuautr3tcNAruRE:C �/� _ % ��.r 1:(I ,( Darc--.03-07-01 <br />PROPERTY/BUSIW 50wwA ❑ OPEFATCR/fAVO ER 00wAvTHO1;1iWAcaff ❑ HARBORMASTER <br />ffAPP_1c,+.W&rx3(ft ff4&+cP�nrrproofh>raudrw?raBartosiyakrhqu4vd Titla <br />AUTHORIIATIOf(T4 RELEASE INFORMATION1 When e0cohl% L the owner Or op<rator of the properly hated atthe above ale address, here by audioax The n:te�ls& et <br />any and al rmlf;, gmtedmi®1 dale arKLW OnimAmerltalhlta assess %'r t miom l*n Io die SANJOAGA ColhmPLUM HEMA Sam= & RflllrY mA1 HL iH CM -K -M a9 scrn <br />a itis avalilable and at the same Erne lis Provided io me or my representative. <br />TYPE OF SERVICE AfQUCBTE�: //7IL K �C /li �/ G '� Ste/ ST / / �G i7 �/'�. <br />COMYFM$. <br />KL-f''L�l� �C/GG %/v����«�-' •E'!r' �T % �5�35 0 �it/CL, iC'G�'L �//>,� <br />INSPU:TOR'sSJGMTURE: COtsrRAcrvR'3Slaru /�? <br />AaPP.OVF_D+9Y' I Y,C EsIpL—^yM#t <br />A35IGNED TO_ EbFLovrEA [tJIT� <br />o rte SMICP Completed (if already completed): 61ERVIeECoOE.. - P rE: <br />06 <br />Fre Amount 'L(� ( Amount Paid (i PiymentDatej <br />Payment Type Check# 1 it n 1 <br />RECEIVED - <br />MAR 13 c00 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH IINISION <br />