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01,10412010 14:25 9165671140 LESLIES POOL SUPPLY PAGE 04 <br />SAN JO,AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARi'Mf:1'1 <br />SERVICE REQUEST <br />........ --- — <br />'i ype of Business or Property FACILITY ID # SERVICE REQUEST <br />/8q3eOcSgO.''-3 <br />i. OWNER OPERATOR CNECK if BILLING ADDRESS❑ <br />I _ I <br />Far,t-'�NAME <br />SIFE DURESS <br />SVNt NY Mr 'ncenn ZIP Cogs.J <br />HOME. Of MAILING ADDRESS (if Different from Site Adeross) <br />P�•nyC. 7? <br />I I <br />RCOUFSTOR <br />BUSINEss NAME: <br />Hom rMAiL1Nc <br />a <br />Ear. <br />Gey-/Lfo.-3"7 <br />CONTRACTOR/SERVICE <br />STATE ZIP <br />LANo Use APPI•ILATION a <br />Bos OL4TRICT Z LotATIOv fcOE <br />CMECKHiii:N� <br />f ! <br />STATE zip <br />/t ,. <br />litl 1.1\t; :1CKINQWLEDGEDIENT: I, the undersigned property or business owner, operator or authorized apow of iame, <br />"1011 ' icl:au that all site andAx project Specific ENViRONNMENTAL HEALTH DEPARTW?NT hourly charges 435c6x; ':t 'ails, ibis <br />Dan. :e ilI he billed tome or my buslioess as identified on this form. <br />;hat ! ha\ -e prepared this application and that the work to be perfumed coil! be dcne in OCc.rdsCr.: iP• '!I ° ...1�....,,... <br />. '..raulcr ( Ode,'. ;;un.:ards, STATE and FEDtatr\L laws. <br />ar�i•t it .ANr`v CIGN.ATt 1RF,:Dn'rE: <br />,. .i. .; I�.a. iletr• <br />�,FL-: OPE:aATOR/M,tvwGnt❑ llTHaaAC1'HOk7tZ6DAt:Gvl �y ^,`'Cn <br />v MENT <br />It , Irr.cic•w.T is not theBruer rtn, proof of author adon to sign is required Lf� <br />\t f 110Rl'LATIOP TO RELEASE iNFOAMATI N; when applicable i, the owneror operator ei ;he propel 1001 (y <br />o div address. hereby authorize the release of any and all results, geotechnical data and/or a,-.•:ir::c:.tai:�!'�". s;s:�n:::+ <br />I:.1i 0to h rnv r Jro1nIN �GNTY ENVIRONNIFNTAL l{EALTFi DIEPARTMENT as Soon as it is availahlC and $AN dt)AiI' 6wcnutA <br />TY <br />III, <br />.- <br />RELU287Ei,. <br />l 441. (;21 <br />A <br />-- . �.----..._ .. �3z( w ..-... <br />EMS EA—�j 2%3 ! DATE: J!' !'Q <br />___..._ - <br />n.., r, nnd.. r; �:r ��..�q �+ !:. a;aaCY :arrpletod;: ; S<s.•rc: CODs; /-i ZZ� i � -' '2 ��9 _ <br />fax Amount: I Amount Paid Payment Date <br />Invoice T .......0 _ �0. - <br />PaynrrntType -- # -CheM" Received y: \x C' _ <br />r.'uzs Del 4)ie fmq�le A l6 (70b --:2 Flo <br />