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09/09/2008 15:28 PAGE 02/02 BURKETTS POOL 2095993 7 01 <br />\fi)k7Jk-L--(11itret lf(18 SITE ADDR S <br />6111. Strea Number Ire ctIOn <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Tvoe of Business or Property <br />01111NkR / OPERATOR <br />SAN JOAQUIN COUNTY ENVIRONMENTAL ITEALTH DEPARTMENT <br />SERVICE REQUEST <br />SERVICE REQUEST # <br />? kizte FACIUTY NAME IS 3 3G <br />City <br />ZIP Strut Number_ <br />CID( <br />_ .----------- ar APN <br />PHONE #1 <br />I I <br />PHONE #2 <br />( <br />REQUEST OR <br />0.6( ( <br />Ext. <br />CONTRACTOR / SERVICE REQUESTOR <br />cHEcK If 13ILLING ADDILESSE1 <br />cl6G( — -sr <br />CHECK If pn,ING ADDRE$1 <br />FACILITY 10 # <br />crr <br />BILLING ACICNOWLEDGEMEIA: I, the undersigned property or business owner, operator or authorized agent of sante, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT <br />hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />also certify that 1 have prepared this application and that the work to be perfomied will be done in accordance with all SAN <br />JOAQUIN' <br />COUNTY Ordinance Codes, Standards, ST a7 I PE L laws. <br />APPLICANT'S SIGNATURE: <br />A11117-A-7 ION TO RELEASE INFol_IAT.-101!_i: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of arty and all results, geoteehrical data and/or environmental/site assessment <br />information to the SAN JOAQIICN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as <br />soon as it is available and at the same time it is <br />CommEwrs: <br />SAN JOA,QUIN COUNT <br />1 SEP 1 0 2008 <br />eN\IIFION <br />MENIAL. <br />°EPP1/45TMEI4T-NVIR0NMENT <br />HEALTH <br />EMPLOYEE if: <br />iT/J:RVIGES <br />ehelt4J60e1 <br />Date Service Completed (if already completed): <br />Fee Amount: ,_.../crc-- , <br />1 Amount Paid \ 0 S , (.30 <br />Payment Type Invoice # <br />V\ • Ca 4r- <br />El-ID 5a-O2-O25 4S-02-025 <br />REVISED 11/1712003 <br />DATE: <br />PROPERTY/ BLISINEsS OWNER 0 OP OR/ MANAG OTHER AUTHORMED AGEN <br />ilAL7 proof o autirorizadon to sign is required Title <br />1.1 APPLICANT is not theLUOV <br />provided to me or my representative. <br />TYFE OF SERVICE REQUESTED: CiR 0:3 <br />Emp,,Ego: <br />SERVICE CODE: <br />Payment Date c_ki b/ 0 ce, <br />Received By: <br />SR FORM (Golden Rod) <br />ACCEPTED BY: <br />ASSIGNED TO: