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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Resorth '5 ' ?O � <br /> / <br /> OWNER / OPERATOR V Vl/ <br /> Tower Park Resort CHECK If BILLING ADDRESS E] <br /> FACILITY NAME Tower Park Resort <br /> SITE ADDRESS Highway 12 Lodi 95242 <br /> 14900 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Hugo Varo CHECK if BILLING ADORES <br /> BUSINESS NAME PHONE # EXT. <br /> Burketts Pool Plastering 209-624-2918 <br /> HOME or MAILING ADDRESS FAX # <br /> 600 N Frontage Rd ( ) <br /> CITY Ripon STATE CA ZIP 95366 <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, Standards, STATE and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : 5/ 11 /21 <br /> DATE : <br /> PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT E] Contractor <br /> If 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative . <br /> % a 1V14:1VT <br /> TYPE OF SERVICE REQUESTED : a.4&r I f< i V VU VI <br /> COMMENTS : <br /> MAY 2 ?®2r <br /> SAN <br /> �AQUIN CCU <br /> HATH 0CPAR �n' <br /> ACCEPTED BY : 1A 0 EMPLOYEE M DATE : t 2 <br /> ASSIGNED TO : EMPLOYEE # : DATE : <br /> J 2 <br /> ✓� ) ! � <br /> Z <br /> Date Service Completed (if already completed) : SERVICE CODE : P I E : I � <br /> Fee Amount : ' Ir (O� Amount Paid3 � OD Payment Date �_ 2� / ��Y <br /> Payment Type Invoice # Check # �S b Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />