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CONTRACTOR / SERVICE REQUESTOR <br />I checx If BILLING ADDRE§.S. El <br />REOUESTOR <br />cJ <br />BUSINESS NAME <br />CXT tef <br />Jo) (/) a <br />HOME Or MozNGeDDISS <br />Crry <br />i_04)1 STATE <br />SITE ADDRESS <br />No rfra Ol <br />97 ,4 Strast Nymbey Direetl NOr <br />HOME or MAILING ADDRESS (If Different from Site Address <br />ZIP STATE <br />ype at Business or Property <br />OWNER / OPERATOR <br />FACILITY ID # <br />(0.& <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS": <br />FAclure NAME <br />A <br />keel rime fro aitettu <br />Cirr <br />PHONE #1 <br />) <br />PHONE #2 <br />Street Numb*, Street Name <br />BOS DISTRICT LOCAT12COCE I <br />LAND USE APPLicATioN# <br />Err. <br />Exr. <br />q -gg <br />Zip C pd. <br />APN # <br />4,__ 24,0- I-3 <br />El-ID 48-02-025 <br />REVISED 11/17/2003 SR FO (Golden Rod) <br />2 /2:.96 c1 017TTL9S9T6 82-V17917602T:0i elb,TTL9S9TE,:woJd 2T:i7T OI2-82-Nrlf <br />I. <br />I TYPE OF SERVICE REQUESTED: POOL tro4/4 <br />Fee Amount: 2 3o <br />Payment Type kk invoice # <br />Cover ookci Rilige c z3 rfclleEirETD <br />AccEPTED BY: <br />ASSIGNED TO; <br />Date Service Completed (If already completed): <br />..:AIMEN73; <br />rti pl&fe ifv\A,(,) 614A- rirot INC-I'L &Twee( va-,6 64, <br />t v.Et <br />19E,J,2-04-/A- <br />-_-_-_-_-_-__ <br />Amount Paid <br />• <br />6 -3c. op <br />Check # <br />ENIPLoYEE fi! cg <br /> NT <br />SERVICE CODE! <br /> .:54( <br />- • , <br />Payment Date <br />Received <br />t? 1 <br />-.Hitili 2 8 2010 DATE: <br />AQU1N CuUNTY DATE: 6, /0 E RON MENTAL <br />DEPA.RT)AENT <br />C_ctC_ <br />FE) <br />11-0 CENE-0 <br />2 3 t_Uld <br />ENVIFi OWENT ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMETT-Q1\ HE4TH <br />SERVICE REQUEST <br />131kLING ACKNOWLEDEMENT: 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 />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, Standar s, STATE a • EDERAL laws. <br />A <br />ab <br />in <br />APPLICANT'S SIGNATURE: <br />i'korEn OWNER <br />IhAst <br />191h4 ?Wit. .y , v , <br />DATE, h 9101 <br />provided to me or my representati ye <br />OPERATOR MANACAR0 OTHER AL ruORIZED Ac ENT* SIINV, <br />e PILLING PARTY proof of authorization !osiglt is required lite <br />INFORMATION: When applicable, I, the owner or operator of the property located at the <br />e the release of any and all results, geotechnical data and/or environmental/site assessment <br />Wry ENVIRONm HEALTH DE.FA FITMENT as soon as it is available and at the same time it is