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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# a k)IM011Y1 pool /�esdtht:ia!L �;eO43371/ OWNER/OPERATOR F-q►m i � _I.�m e p , 'oo n e . lKevin yo U n CHECK if BILLING ADDRESS❑ FACILITY NAME 1 ,y,n„I t h t P O O N mc. SITE ADDRESS J J 100 E Li b t Y tq R°o d' Ga ►t q�3z- Street Number Direction Street ame Ci -Zio Code HOME or MAILING ADDRESS (If Different from Site Address) RPA �9EN Street Number Street Name ` /r CITY STATE ZIP AfAR In PHONE#1 ExT. APN# LAND USE APPLICATION# (91u ) -741- �2.J 0 DO -1 14 0 3 � A.-OA,. COU PHONE#2 , ExT• BOS DISTRICT L� LO CONTRACTOR / SERVICE REQUESTOR REQUESTOR Kevin �O i ' CHECK if BILLING ADDRESS BUSINESS NAMEFa m -ti wI t �p o o S P C , (ql& 74-1 - (12-1 1DExr. HOME or MAILING ADDRESS ,^ o ' O l FAX# P. ( ) CITY 'i j, V STATE Cd ZIP q6 W 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 FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNERP OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLicANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: III nob l G rl COMMENTS: ��q�Q S 1 1 V �t W Ct S i W"may l e i y] car d�er to q n OR 1C �Q�/�'Y�1 , vet& tHaf leach lore on fefr",' 7y-��1�J FIs r7oj in 0se . t be f,� ycfecl ` �). �in� iruVek to the V05s ane/ r,,V P y P �irr� sfafc� � be CALL(209)953-7697 ACCEPTED BY: FOR INSPECTION. EMPLOYEE#: DATE: 311<) aj 48 HOUR NOTICE ASSIGNED TO: DA REQUIRED. EMPLOYEE#: / DATE: 3//0/,7/ Date Service Completed (if already completes. SERVICE CODE: d / P/E: yo7po? Fee Amount: Amount Pai Or� Payment Date �D Z Payment Type �' Invoice# Check# 12— 7 1 Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003