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07,"1:'22005 15: A9 464?.38 ENVIRONMENTAL HEALTH PAGE 02 <br /> SAN JOAQt -"OUNTY ENVIRONMENTAL HEALT' EPARTMEN'T <br /> SERVICE REQUEST <br /> Type of siness or Property FACUTY ID 0 SERVCCE REQUEST# <br /> v� clr 5 Pcici v (-f <br /> OWNER 1 OPERATOR CHECK If J--�,uyo AoqffL*s <br /> T Tracy Unified School District <br /> FAmrrY NAME <br /> Tracy- Rizh-School— <br /> SfTEADDRESS 315 E . 11th Street , Tracy , CA 94376 <br /> Stmt"do*" p )PI, street Name <br /> HOME of Mawe ADDRESS (If Diffemnt from site Address) <br /> Street Number --- <br /> +.-----— <br /> CITY STATE <br /> , <br /> rim. APN LAND Use APPucA"ON 0 <br /> `�E41 t .JUL 15 <br /> - — e,,. SOS DISTRMT NVIF3U H�°t <br /> Pxo►tE r2 <br /> o VICES <br /> CONTRACTOR/SERVICE REQUES'TOR <br /> RLQUESTOR ,� --- — C4ECKIfa O-0-M:ss_� <br /> CIA K f-1. <br /> PNXE R EXT. <br /> BUSINEss NAME 0 8 7 41-5 8 <br /> _ Aquatic Commercial <br /> 71 <br /> HOME or MAtuNc A FESS FAX s <br /> 20340 Orchard Road ) - <br /> 1 216 <br /> CrrY STATE zip i <br /> Sarato&a ,- CA 95070 <br /> Bx1.I�1t1G ACICNONVI&DGS.hIENT: 1, the undcrsiped property or business owner, operator or authorised agent of same. <br /> acknowledge that all site and/or project specific Den IRONMENTAL HEALTH DEPARTMENT burly cbarges associated with this projector <br /> activity will be billed to mt or my business as identified on this form. } <br /> I also Cd tify that I have prepared this application and that the work to be perforaned will be done in accordance with all SAN JOAQVW <br /> CouNTX Ordinance Codes,Standar and FEDEML laws• <br /> APPLICANT'S SIGNATXW. J C DATE: <br /> PxorruTr I i¢USCYESS OWNER 13 OrEanro�a!Mww�csx ❑ Orerat A otetzao ACW'TA1_CU%�5�L Til /vJ <br /> IfAPPMCA1,tr is not theBIUJNG d R7Y.proof o authorization to sign is required TJr1c <br /> Fw F INFO 'Tl[ON: YVbcn applicable,1,the owner or operator of the property, located at th-: <br /> AU TTI0RIZA' ON TO$EL <br /> above site address, hereby authorize the release of Amy and all results, gcotmhtucal data and/or euvisonmeutal/site assess>nt rn <br /> infor :Luou to the SAN IOAQUU4 COUNTY ENVnk0NME;WAL HEALTH DEPARTMENT as anon as it is available and at tLe satne time it i <br /> provicted to me or My representative. <br /> I YPE OF SERWE REQUESTED: �V.)i W�•rv� t W I p f V yVl �_� - <br /> �T r <br /> Comm <br /> �--EMPLOYEE#: DATE: -j (r S(n 5 <br /> AccirErt:o Bv: --L�L(�'�I r2-�4 <br /> EMPLOYEES: .jL'y(�^-7 DATE: -7 ��S( pc- — <br /> ASSIGNED TO: u E5 C'6 <br /> SEaviCF cove: O C f PIE: .3 L:.i?3 <br /> j Veto Service Completed (if already COmP1011ed): pAn16nt Date ( �D <br /> Foe Amount:7� 13- 0-C) Received <br /> Paid �j 3, lT1 <br /> Check# 3 Received By: <br /> Paynwnt Typa v' invoice S l (3 <br /> SR FORM(Golden Pied) <br /> E t10 4602-025 <br />