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4 02/23/2001 08:41 2094683433 FIF-iH FLUOR pgt;F it!, <br />_ SER ;CF.. RFgI)EST <br />Type of Business or Property t -AGILITY ID t# <br />MARINA N-483 <br />Owt m l QPERATOR <br />THE PEGASUS GROUP / VILLAGE WEST MARINA <br />FACH.0 NAME <br />VILLAGE WEST MARINA <br />SITE ADDRESS <br />6649 5,,.,ba.,t,., a K,EMBARCADERO DR ot, <br />Mailing llyddre33 Of 9iNerent from Site Addressl <br />PHONE #1 Err. 11PN <br />PHONfi#F2 ar. _ BOSDrsnu-7' <br />CONTRACTOR SEttvICE REOUESfOR <br />REOUESiaR <br />S0,"ACE RF-QUE.4T <br />00 r7 � <br />SILL NG PA;Zry F <br />Lu, o USE APPLcATIon # w <br />IUXAR ttCODE <br />QtWN3 PARTY ❑ <br />Bustre:ss NAnre /n�/t 17 PHogE? <br />Wiu"r, Arrou5s FAX# <br />�� ,� ;.27� :��� s-:37-'37 <br />CITY L �i��S -ra-M La )�l 7 <br />I <br />BILLING ACKNCWI.EDGEMENT: I, the undetttgoed property or business owner, opet;lvr ur auftAced agerrt of same. adcmwiedge that ell aruitnr projea specific <br />PUBLIC HIKTli Seca >r9 ENY6t0M1iHrTAL[jEALTH awron tgW1T d fges sswmWd with this prcJec Cr activity wli be btped to me ar my business as Idenoled on this Scan <br />I also w0f Ihat I have prepared this apprkmIlon and that the work to bQ pariorrrwd unil be done in aeoordanea wrier 21 Sue J44MtH C4Wry Qi*rsacs Codas, 5tandardV, SrATE enc <br />FEDE,7AL lays. <br />APfucwSwTm; _ �.i 1:�/ ,(� o4n: 03-07-01 <br />PROPPAIY/SusiwwOwNm ❑ CKRAtCft/MArvnarR OINERAurHcp=Amlfr p HARBORMASTER <br />NAPP-Nrwr.�S rxY the UW.V Pam; proof d2u&0t:2dvrr to sign k rMbvd Ti f to <br />AUfHrJRIZATI N TO RELEASE INFORMAT O When apoimhle, L the awner or operator of t)te property bcatr4 at the above sde,ddms, hereby autltatim dre teleace of <br />arty and al ramlt,, geate&nica) date t� the Sm jcAcLw CouHTY Plrefrc HEALTH SEKyMS I!ffM0NraNiAL NFxTH Glv�aa7 aq Sr�n <br />a itis wailabla and at the same Time R iS provided to me or my reprr$wrIa im <br />TYPE OF SERVrCE REgUESTED: / lk K �Il�/LS�/ /I?/ <br />CaN>aexrs; � r <br />����L�91-� f�/f%f/Gl�% G�f�f� .SE �s l'�' /N C1tiGr`��� �� T��✓� <br />�C'� <br />"v,, ,73 <br />//r/c< <br />INSPO:TOWs Siowuw CCK RACTOR'3 3113MATU-- <br />APpRovw8: EM - r_ <br />ON,,: <br />Asmm4wT0- EmFfayrr #: <br />DAM <br />Oahe Service Campitted (datrady t:ompltltt►d): s tcs:cooE± . .� <br />PfI-. <br />Amount Paid 'w Payment Date <br />Fee Amount Z � 1 — — _j <br />] 13, 0 <br />Payment Type 4lwico # Ght A # I <br />ll a.Ned : <br />V I -N I r v r t— r v <br />RECEIVED <br />MAR 13 2001 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICrS <br />RIVIRONMENTAL HEALTH MVISION <br />