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SAN JOAQUIN(:OUNTY ENVIRONMENTAL HEALTH DLeARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fA 01/U 9'7gq S R <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Linkoln Park Pools <br /> SITE ADDRESS S Powers Ave. Manteca 95337 <br /> 245 Street Number I Dime tion Street Name cjty Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number SVeat Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME PHONE# Exr. <br /> Burkett's Pool Plastering 209 624-2921 <br /> HOME or MAILING ADDRESS FAX# <br /> 600 N.Frontage Rd. ( I <br /> CITY Ripon STATE CA ZIP 95366 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvtRONmENTAL 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: SQan, ) <br /> a., m DATE: 10/31/2019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 environmentaVsite 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. PA Y4 <br /> TYPE OF SERVICE REQUESTED: Commercial Pool Minor Remodel RE T <br /> COMMENTS: D <br /> NOV 14 20 g <br /> V1R N C <br /> EN OAQUI OU <br /> HEALTH DEpME AlE TY <br /> ACCEPTED BY: EMPLOYEE#: DATE: .L I <br /> ASSIGNED TO: EMPLOYEE M DATE: f Cl I <br /> ^ r 1 <br /> Date Service Com ted (if already completed): SERVICE CODE:14 1 '�U PI : [� -Z- <br /> Fee <br /> Fee Amount: Amount Pai 3o 6-2) Payment Date <br /> Payment Type Invoice# Check# gS(S.�o Raca14e of By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />