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SAN JOAQUIN, JNTY ENVIRONMENTAL HEALTH � ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Pool/Spa at New Apartments <br />PHONE# ExT' <br />949 493-9548 8 <br />52ao7gi 0 <br />OWNER/ OPERATOR <br />LTMT Tracy, LLC 1156 N. Mountain Ave., Upland, CA 91785 CHECK If BILLING ADDRESS <br />FAcaRY NAME Harvest in Tracy <br />CITY San Juan Capistrano <br />SITE ADDRESS <br />DATE: n f <br />I Henley Parrkway/w.Grant Line Rd/ <br />Tracy <br />EMPLOYEEM 6`� <br />Street Number <br />Direction <br />Interstate 2 t a <br />SERVCECODE: 23 <br />C <br />ZipCode <br />HONE or MAILING ADDRESS (If Different from Site Address) <br />Payment Date <br />Street NumMr <br />Invoice # <br />n Name <br />CITY STATE <br />ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />( <br />238-600-25/26/27 <br />PHONE #2 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Lisa Zoscak <br />CHECK If BILLING ADDRESS El <br />BUSINESS NAME <br />Aquatic Technologies <br />COMMENTS: <br />PHONE# ExT' <br />949 493-9548 8 <br />HOME or MAILING ADDRESS 32232 Paseo Adelanto, Ste A <br />ACCEPTED BY: <br />FAx# <br />(949) 276-7705 <br />CITY San Juan Capistrano <br />STATECA ZIP <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, Standar STATE and FEDERAL laW <br />APPLICANT'S SIGNATURE: \ DATE: 22 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ 6ANAGER ❑ OTHER AUTHORIZED AGENT C4 A9pnt <br />yAPPL/eANT is not the BILLING PARTY proof of authorization to sign is required rate <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: New Swimming <br />po o l a n d Spa <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE M 6L/3 <br />DATE: n f <br />AssiGNEDTO: <br />EMPLOYEEM 6`� <br />DATE: --;:> /d10(/ <br />Date Service Comp ted (B already completed): <br />SERVCECODE: 23 <br />PIE: o 2 <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />