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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Hotel <br />FACILITY ID # <br />/ 22 (2 <br />SERVICE REQUEST # <br />St2-1118614(41- <br />OWNER / OPERATOR <br />1.4 0 it_ IS L L C <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Best Western <br />SITE ADDRESS 6411 <br />Street Number <br />1/V <br />Direction <br />Banner St <br />Street Name <br />Lodi <br />City <br />95242 <br />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. <br />(26 7 - 3 6 ° Z <br />APN # LAND USE APPLICATION # <br />PHONE # EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />HglIrser.baad..P-4spotT NI‘i Cle'N .6"( illAA lc, 4' r CHECK if BILLING ADDRESS I C <br />BUSINESS NAME <br />Hammerhead Pools <br />PHONE # <br />( 916)753-5584 <br />EXT. <br />HOME or MAILING ADDRESS <br />P.O. Box 1867 <br />FAX # <br />( ) <br />Ci-re <br />Rancho Cordova <br />STATE CA ZIP 95741 <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: 7/1-e:Cia-421711-ditz:Vt, DATE: "A 17//2- <br />PROPERTY / BUSINESS OWNEREI OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT IN 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... <br />Pa <br />ivrrit is <br />PAY provided to me or my representative. E VED <br />TYPE OF SERVICE REQUESTED: mAR 0 1 2n23 <br />COMMENTS: own' Replaster Swimming Pool & Spa. Install new Drain Covers P. 10A011IN C <br />I ',VIRONMENTAL <br />, , I 111 Of PARTMEN1 <br />Pool Drain Covers - 2 - R12MF101 274 GPM <br />Pool Equalizer Covers - 2 - 6HPHA101 122 GPM <br />Spa Drain Covers - 2 - 18MF101 293 GPM <br />ACCEPTED BY: c y r L , -,....e c 0 <br />EMPLOYEE #: DATE: 2_,z_g_ ._..L....3 <br />ASSIGNED TO: c" <br />L-& t, 'f';.^ < <br />EMPLOYEE #: DATE: 2._ —2A--- , 7,3 <br />Date Service Completed (if already completed): SERVICE CODE: lif 5 2 _3 P i : 3 4,0 )--- <br />Fee Amount: i -2, — S '1-1 Amount Paid t al, Payment D te f. i Ajg, 2-3 <br />Payment Type l'=-,) i.-- Invoice # gpeali 151-Crqs-'gki Received By:J(1-W <br />EHD 48-02-025 <br /> 2 /24/2 2-3 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />PPs2i4