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SAN JOAQUIN –jUNTY ENVIRONMENTAL HEALTH L-. 'ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Health Club <br />FICuLwivieD <br />ANIS 11 1019 <br />SAN JOAQUIN COUNTY <br />HFANN EPMENTAL <br />linw <br />�I <br />EMPLOYEE #: / 2 <br />CF <br />OWNER/ OPERATOR <br />IN SHAPE Health Clubs <br />658-5420 <br />CHECK if BILLING ADDRESS <br />FAcINP1A 1�APE Health Club #2 <br />(Outdoor Pool & Spa) <br />3 <br />SITEADDRRESS <br />6545 <br />Fee Amount: <br />Embarcadero Drive <br />Payment Date <br />Stockton <br />95219 <br />Street Number <br />Direction <br />Street Name <br />city <br />75P Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 6South <br />EI Dorado Street, Ste.600 <br />S Veet Number <br />Street Name <br />ci%tockton <br />STATE CA ZIP 95202 <br />PHONE #1 En. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 472-2450 <br />PHONE #2 Elm. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />VinceB Marker <br />U <br />FICuLwivieD <br />ANIS 11 1019 <br />SAN JOAQUIN COUNTY <br />HFANN EPMENTAL <br />linw <br />NES NAM <br />t�%NOAqua�tics <br />EMPLOYEE #: / 2 <br />PHONE# <br />En. <br />909 <br />658-5420 <br />HOME Or MAILING ADDRESS <br />FAX # <br />3 <br />245 W. Foothill Blvd. <br />Fee Amount: <br />( ) <br />Payment Date <br />CIAAonrovia <br />STATE CA <br />ZIP 91016 <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: V. kakkZP <br />03/27/19 <br />PROPERTY/ BusmssOWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORizEDAGENTIR Director of Operations <br />IfAPPLIC4NT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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 />AYME <br />COMMENTS: <br />U <br />FICuLwivieD <br />ANIS 11 1019 <br />SAN JOAQUIN COUNTY <br />HFANN EPMENTAL <br />linw <br />ACCEPTED BY: <br />EMPLOYEE #: / 2 <br />DATE: 12 <br />11 <br />ASSIGNEDTO: <br />EMPLOYEEM 21 <br />DATE: tf fLel I <br />l^ <br />Date Service Com Ieted (if already completed): <br />SERVICE CODE: <br />3 <br />P 1 E. Q/ <br />7b f� <br />Fee Amount: <br />Amount Paid 30 [t. — <br />Payment Date <br />4 I I y/ l <br />Payment Type I SA <br />Invoice # <br />Check # <br />Received By: NJ <br />EHD 48-02-025 9'9 b 3 3,;L 11 -- SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />