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01/04/2010 14:25 9165671140 LESLIES POOL SUPPLY <br />\\\VVII II <br />JAtA 4 V%1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIFNI I <br />�r iT I ENO" SERVICE REQUEST <br />ENS <br />PAGE 01 <br />pN l t> ttl�Y r P;Dperty -- <br />FACI,LI(ID <br />SERVICE REDU�EST ? <br />1vr <br />16 JT <br />VI <br />CJ <br />OWNER ! OPERATOR <br />CHECK if BSI ,LINO ADO?ESS ❑ <br />Fa ;: eAaaE Sur► r r <br />$IIF. ADDRESS <br />B�k� �t•d, <br />elr�L� <br />/fi <br />S S: _,de9. <br />StMetNU bw irve4esn <br />~HOME <br />c <br />or MAILING ADDRESS (It Different from Site Address) <br />(illy STATE ZIP .� <br />rgr4F 71 <br />LAND USE APPLICATION $ <br />Ouirm LGI:AtIO//N Cf1oF <br />rr4; Nr 2 Ear. <br />am <br />CONTRACTOR/ SERVICE REQUES•I.OR <br />REGUESTOR �( CHECK I}SII.ING ADDR•Fr--Ej <br />J Ec I <br />BUSINESS NAME • r' <br />HOME or MAILING ADDRESS F <br />16) _2-1/�1 - — <br />I:" f = /_ P � STATE �"'�— 21P L/ 0'1/% <br />iit; I I�NG A('IZ\OWLEDGEMEVT: 1, the undersigned property or basiam owner, operator or authorized agent of Same. <br />all site an&,)r project specific ENVIRONMENTAL HEALTH DEPARTMENT IIOurly charges a>soc:iavad ual, <br />..:.u•. it, will be hillcd to me or my business as identified on this form- <br />'Iia!! <br />orm"!ha!! i:<:v- pr-pr:red this application and that the work to be performed will be done ir. <br />d:,.:IrcJ I Bride'.. wndard& S1 ATE and FEDERAL laws. <br />10111 11 A N 1's sgiNATI IRF: n.,,TF.: _1...._ ... yPI D .... .. .. . <br />n�'.�,F:e.:)rt'�..R❑ OPGRATOR/ IIANAGSR G OrHERAUTHORTUDA4-FM P AJAyME-WT <br />no: rherrLbEgLda6proofofauthorftuHaRmsignisrequired, F+LCEIVED <br />0 _i 140RI7.ATION TO RELEASE INFORMATION: When applicable,1, the owner of operatur of lite prupertp u:naled at Jtc <br />lite address, hereby authoritc the release of any and all results, geotechnical data and/or <br />.W, ri (.+ OIC Y.'.\ J0 A')InN ('N;N! Y F.NVIR9NMRNTA4 NEA4.Ttt DEPARTMENT as Soon as it is availahlr and c •ar`n' !:m<' 'I <br />..,,. aro ..r rm repro<Cnuetiee. AN JOAAQUIN COUNTY <br />.:. �c.+.{C2 Re��25TEG. 'D ENV ONMENTAC"" <br />r OOL S'i��} �i�)4!�/mac NOOEL Ls4N <br />CV-(qaqM <br />r�lruc {w.s�i•1 MG1�n �ru�rt tA✓e� k�A Iys�ttL '��,� aP!%!'t7Yt <br />Co�G� alto aid 2 to✓ir1 �° �iit� /!mss dnd W40 X1401" <br />Ry....__ 0 Lt _vE i 4-4 _. <br />.,¢yi,.:Npr1,O` JoEO�razt_ <br />4rc.Nnount' '�.r.3D• Amount Paid <br />Pav went Type invoice # <br />, .•,rI I • , i.�nOl rl/fVI �11 a n1 U' <br />E10PLOrEE #: JATF: III S d <br />SV'--r-CE-7C=4; 2—Z <br />m PI ayment pate <br />rived By: <br />zy�r9� �y,°jb <br />