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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 24HR Fitness Club 11,24 400 Col yS9 <br /> OWNER 1 OPERATOR 24HR FITNESS,1265 Laurel Trec Lm Carlsbad,CA 92011 CHECK If BILLING ADDRESS❑ <br /> FAcILnYNAME 24HR FITNESS#535 <br /> SrTEADDRESS 1090 1 N North Main StreeC Manteca,CA 95336 <br /> Street NumMrolrwfo. "A" crN zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APNA LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Ext. BOS CusnIt r LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR Mike Reinhardt,AOA Inc. CNEcKNBILuNo ADDRessIl <br /> BUSINESS NAME PHONE# Exr. <br /> AQUATIC QUALITY ASSURANCE, INC. <br /> HOME or MAILING ADDRESS FAx# <br /> 6062 Corte Del Cedro (760 ) 431.1464 <br /> CITY Carlsbad, STATE CA ZIP 92011 <br /> SH,LING ACKNO)nEDGEMENT: 1, the undersigned property or business owner, operator' or authorized agent of same, <br /> acknowledge that all site and/or project specific E•NVIRWAiDrrAI.HEALTTI 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 0 <br /> COUNTY Ordinance Codes,Standards.STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /� _�_ DATE: 12/8109 <br /> PROFEHn'/BUsm ESSOWNER❑ OPERATOR/MANAGER ❑ 0r1R;RAVr"oRIZF;o Acrsr® Projects Administrator <br /> /f APPLICANT Is nor fhe Blun'C PANT):proofof authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby nuthorize the release of any and all results. geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COU14TV ENVIRONMENTAL HRALTu DEPARTMFM as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: INSTALLATION OF VGB-COMPLIANT DRAIN COVERS REQUIRED FOR ALL COMMERCIAL;hOM-'AND <br /> SPAS(SEE ATTACHED PLAN DETAIL) RECEIVED <br /> MAY -5 2011 <br /> SAN IV-IwNv % <br /> CNY C.♦4'i . <br /> ACCEPTED BY: EMPLOYEE#: 90ST DATE: S520Af <br /> ASSIGNED To: C6BPq -2 �- EMPLOYEE#: 34-7 DATE: <br /> Date Service Completed (if already completed): SEImcE CODE: T3124.2- 1 3 I P f E�06 O2 <br /> Fee Amount: 4 4i o o Amount Paid 1.., i Payment Date 5 S <br /> Payment Type Invoice# Check# 3 5�o d Received y: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />