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SAN .IOAQUL OUNTY ENVIRONMENTAL HEALTH D. ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />1 <br />BUSINESSNAME A'dafit5 PoolO(,'G IC:I rr C+S <br />F ly �� <br />FACILITY ID # <br />.n 06),S/ 0 <br />SERVICE REQUEST # <br />FAX# <br />(w) 3s -ado / <br />CITY GCfowe-4-1c <br />STATE CA zip g5ga9 <br />ASSIGNED TO: <br />17 <br />OWNERIOPERATOR <br />fR I �'nn <br />r� <br />LI rntW <br />LP C&I <br />CHECK If BILLING ADDRESS <br />FAcim NAME A1�bor Mob1 i <br />/'"t <br />Nome{ <br />Fee Amount: Z,2JOU <br />Amount Pai � U <br />SITE ADDRESS <br />Payment Type <br />I'U. �11�hlAl Gtl <br />q'� <br />G[fyl�V <br />,l <br />quad <br />/ /(9�ro Street Number <br />Direction <br />Street <br />Nama <br />I <br />Zi C d <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street N.m. <br />CITY <br />STATE <br />ZIP <br />PHONE#1 <br />En. <br />APN# <br />LAND USE APPLICATION# <br />( ) <br />oil -73300-7 <br />PHONE #2 <br />EX . <br />BOS DISTRICT <br />CODE <br />( ) <br />INN <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORd� /� eu 2 <br />/V (� L.� <br />CHECK If BILLING ADDRESS <br />1 <br />BUSINESSNAME A'dafit5 PoolO(,'G IC:I rr C+S <br />F ly �� <br />PHONE# EV' <br />914 n£ -a <br />HOME Or MAILING ADDRESS -"J j )9 ^ �` o �L <br />/ (� r <br />FAX# <br />(w) 3s -ado / <br />CITY GCfowe-4-1c <br />STATE CA zip g5ga9 <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 Or <br />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 wort We rformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE a FERAL laws c�, /d <br />APPLICANT'S SIGNATURE: DATE: <br />�/D <br />PROPERTY/ BUSINESS OWNER El OPERATOR/MANAGER IJ OTHER AUTHORIZED AGENT <br />lc.i <br />If APPLICANT IS not the BILLING PARTY. Proof Of authorization t0 Sign Is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It is provid� me or <br />my representative. n Yom_ <br />TYPE OF SERVICE REQUESTED:RPPO�4 C) <br />G L <br />COMMENTS: B <br />F ly �� <br />ooh <br />NP <br />pgRrM'1Nr <br />ACCEPTED BY: <br />EMPLOYEE#: <br />`,F <br />DATE: a - 7�- /S" <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): 7 <br />SERVICE CODE: <br />`/ :Jkila <br />Fee Amount: Z,2JOU <br />Amount Pai � U <br />Payment Date m <br />Payment Type <br />Invoice # I <br />Check # �� C? <br />Receifed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />