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SAN JOAQUIN C rNTY ENVIRONMENTAL HEALTH T 'ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />El <br />SERVICE REQUEST # <br />Pool/Spa at New A artments <br />I��`J <br />BUSINESS NAME Aquatic Technologies <br />4 9 <br />q�(�pG�ifl4p� <br />OWNER / OPERATOR <br />En. <br />493-9548 118 <br />LTMT Tracy, LLC 1156 N. Mountain Ave., Upland, CA 91785 CHECK if BILLING ADDRESS <br />FACILIry NAME Harvest in Tracy <br />(949) <br />SITE ADDRESS <br />CITY San Juan Capistrano <br />I Henley Parkway/W.Grant Line Rd/ <br />Tracy <br />Street Number <br />Direction <br />Interstate 205Street Name <br />CI <br />ZIp Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Invoice # <br />Street Number <br />Received By: <br />Street Name <br />CITY STATE ZIP <br />PHONE #1 Ex . <br />APN # <br />LAND USE APPLICATION # <br />( ) <br />238-600-25/�z6f23 <br />PHONE R ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />pool and Spa <br />El <br />Lisa Zoscak <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Aquatic Technologies <br />4 9 <br />PHONE# <br />949 <br />En. <br />493-9548 118 <br />HOME Or MAILING ADDRESS 32232 Paseo Adelanto, Ste A <br />(949) <br />276-7705 <br />CITY San Juan Capistrano <br />STATE CA <br />ZIP <br />9267.9 <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, Standartf, STATE and FEDERAL law <br />APPLICANT'S SIGNATURE: 11M.0 L DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ 6ANAGER ❑ OTHER AUTHORIZED AGENT AtlJent <br />I, f APPLICANT 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 ENVIRONMENIAL HEALTH DbPAxI MENT as soon as it is available and at the it is <br />provided to me or my representative. AIL-. <br />- IM� <br />TYPE OF SERVICE REQUESTED: New Swimming <br />pool and Spa <br />COMMENTS: <br />HV JORONINCORN! <br />FACTy DE SN7AL <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: / - <br />Date Service Completed (if already completed): <br />SERVICECDDE: SZ' <br />PI I <br />Fee Amount: <br />Amount Pa' &0Y. OD <br />Payment Date <br />L� <br />Payment Type L JC <br />Invoice # <br />Check # 5022F <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />