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RECEIVED <br /> • FEB 14 2018SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DLeARTMENT <br /> ENVIRONMENTAL SERVICE REQUEST <br /> TypePaERNTYWOWNSerty FACILITY ID# SERVICE REQUEST# <br /> High School <br /> OWNER/OPERATOR <br /> Tracy Unified School District CHECK It BILLING ADDRESS® <br /> FACILITYNAME Tracy High School Swimming Pools <br /> SITE ADDRESS East 11 th Street Tracy 95376 <br /> 315 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) W. Lowell Avenue <br /> 1875 Street Number Street Name <br /> CITYT racy STATE CA ZIP 95376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 830-3245 233-370-10 <br /> PHONE#2 ExT• BOS DISTRICT F <br /> 5 OCATION CODE <br /> ©n0'3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Greg Cannon CHECK If BILLING ADDRESS <br /> BUSINESS NAME Aquatic Design Group PHONE# E"T. <br /> 760 438-8400 <br /> HOME or MAILING ADDRESS FAX# <br /> 2226 Faraday Ave. ( 760) 438-5251 <br /> CITY Carlsbad STATE CA ZIP 92008 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2/14/17 <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT 19 Facilities Director <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title PAY <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the propertli <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site a <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thAlraeime it is <br /> provided to me or my representative. 5 201, <br /> TYPE OF SERVICE REQUESTED: 61 ( f&ex 6,h—,c K ENViRQ6/Ncp <br /> COMMENTS: plan check for Tracy High school swimming pool circulation equf <br /> rennovation and replacment . <br /> ACCEPTED BY: /► o, el I' EMPLOYEE#: L��� DATE: 1 I (C <br /> ASSIGNED TO: I ` r LA{5 cc? EMPLOYEE#: f� LT/_ �l DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: +��Z PIE: 3601 <br /> Fee Amount: G ` Amount Pai L-I -0'�) Payment Date <br /> Payment Type 049Gk Invoice# Check# !�> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />