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i N Y SAN JOAQUIN a_JUNTY ENVIRONMENTAL HEALTH L—ARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR CHECK if BILLING ADDRESS FACILITY NAME Neplus Apartments SITE ADDRESS Neplus Ct. Lodi 95242 321 Street Number Direction Street Name city Zip Cod. HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 Exr• APN# LAND USE APPLICATION# ( , 0 35330 , PHONEW En. BOS DISTRICTLOCATI CODE ( ) O CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESSE] BUSINESS NAME PHONE# En. Surkett's Pool Plastering 209 624-2921 HOME Or MAILING ADDRESS FAX# 600 N.Frontage Rd. ( ) CITY Ripon STATE CA ZIP 95366 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standards, STATE and FED,ERRAL laws. APPLICANT'S SIGNATURE: i5tk, n, I I a,44-m DATE: 7/8/2019 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® /fAPPLICANT is not the B(LL(NG PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anda time it is provided to me or my representative. ENT TYPE OF SERVICE REQUESTED: Commercial Pool Minor Remodel ED COMMENTS: JUL 0 9 2019 E�AQUIN RONMENO�TY HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE#: &- I DATE: ASSIGNED TO: EMPLOYEE M ( '�( S DATE: Date Service Compl ed (if already competed): SERVICE CODE: P I O Fee Amount: Amount Paid CIE) Payment Date Payment Type �. Invoice##, Y '�r(1I Check# Received By: EHD REVISED 110 17/2003 dC t a" w�^ e) *3; (-7 SR FORM(Golden Rod)