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SAN JOAQUIN _ JNTY ENVIRONMENTAL HEALTH 11 SERVICE REQUEST .RTMENT Type of Business or Property FACILITY ID # SERVICE REQUEST # Health Club CHECK BILLING ADDRESS B'VivoSAC I EMPLOYEE #: `L [ (f ej OWNER I OPERATOR ics IN SHAPE Health Clubs 658-5420 CHECK if BILLING ADDRESS FAci"A TAPE Health Club #2 (Outdoor Pool & Spa) SERVICE CODE: SITE ADDRESS 6545Embarcadero I Drive Amount Paid 30 _ Stockton 95219 Street Number Direction Streat Name Received By: city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 6 South EI Dorado Street, Ste.600 Street Number Street Name Ci%tockton STATE CA TIP 95202 PHONE #1 EX . APN # LAND USE APPLICATION # (209) 472-2450 PHONE #2 Ez . I I BOB DISTRICT LOCATON CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR if X Vince Marker U'VC►D CHECK BILLING ADDRESS B'VivoSAC I EMPLOYEE #: `L [ P ics 909 658-5420 HOME or MAILING ADDRESS Date Service Completed (if already completed): FAX# SERVICE CODE: 245 W. Foothill Blvd. P 1 E. J / 2 16 ( ) Amount Paid 30 _ CITMonrovia STATE CA ZIP 91016 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 laws. APPLICANT'S SIGNATURE: V ual-ka- DATE: 03/27/19 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGENT15a Director of Operations If APPLICANT is not the BILLING PAR Tr 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 assessment information to the SAN JOAQUIN COUNTY ENviRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: , Ar tllE COMMENTS: U'VC►D 12 2019 SAN JOAQUIN COU HEALTH EpMEN7gL iY ACCEPTED BY: EMPLOYEE #: `L [ DATE: 1� ASSIGNED TO: EMPLOYEE #: 6 ' l ` DATE: fl 12-1 t Date Service Completed (if already completed): SERVICE CODE: 7 P 1 E. J / 2 16 Fee Amount: Amount Paid 30 _ Payment Date 4. I I Zl l Payment Type SQ Invoice # Check # Received By: EHD 48-02-025 cg-A� , 9'9 b 3 -3 ,'1 % SR FORM (Golden Rod) REVISED 11/17/2003