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j 1, I ' �..��-,...r• `c <br /> SEI1sd1C <br /> Type cf Business or Property —-- SERVICL REQUEST# <br /> �A <br /> bonl SP-104160W-�mv <br /> OWNER/CIOERA OR CHNCK It en�rHc�,Q ass 0 <br /> Tracy Unified School District _ -- <br /> fA,1—u;r NAME <br /> SCC E ADDRESS 315 E . 1 1 t h Street , T r a cs"N A 94376 <br /> zla c,ae <br /> r. _ SQreMNoenbcr _ �ireetren�� ,,,�„ - <br /> HOW or N.A10*4;ADDRESS ltf vifferew from site rwdross) <br /> StreetNurt,ber w Stre sro�-- �_-- <br /> titTv <br /> STATE ZIP <br /> 6�r taE � - - —•-_• - �` E'er' API! t.Arau USE APPLFcA-noN# —�— <br /> Pr+otrs 1Z z:xT. SO$DiS7rucT LOCATION Coote <br /> CONTRACTOR/ SERVICE REQUEST_OR — <br /> FZEI�LlE C,+ECx if ��! a�oRE55❑ <br /> Richard Young ptb+ N -- �-- <br /> i�uslrJ�ss <br /> _ A jj a t i —C-Q m m.,u r c i a 1 . <br /> H>�E or MAl uyG AUDF21ESS FAX R <br /> 20340 Orchard Road t 1408T867-121 _._ <br /> STATE Z!P <br /> _ —(I A ------� 7 e <br /> L... 3..r a.L a4 a .... - - <br /> � I X 401%)VILEDrG1!!iFN' : I, the undcrsiped property or business owntr, oYacrator or authorized agent of same, <br /> aeloornHleclgc tact all site and/or pray ct specific ENViRONMMAL Hw rF DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to tale Or MY(business as identified on this ibrm. ; <br /> I also certify that I have prepared IlW5 application and that the Work to be performed vdil be dour in accordance"th rdll SAN Ju"Qm <br /> Cc b,-N-z y'Ordinance(':odes.Stordards,STATE and FEDERAL laws. <br /> ?F-j,,,1CAl+NT'S a"IGNAfiUM — <br /> prcOPEnT Y 1 <br /> BUSKNESS SS()wtaFu rs� Orr,*ATOR/MANAGER ❑ OT}�Ert irT410RI7�ED AGENT ED C o n s u.1 reefs <br /> 1j'APPLJCX1a k1z nor the qty PAW,proof of authorization to sign is required located at the <br /> T O jr!) t 4RM 4�TT4T : When applicable, the owner or operator of the property <br /> A�,w O N jr!) _ <br /> a�UVC Iti u.to thegSAN JOhQVTN Lim rNTY ENVIR1JN�o6NTA�1.HEAI.and lTii DEPARTMl results, ENT as soon al data <br /> ait is zvailabie ab�t tbo same gtime it is <br /> infoem.tsv . <br /> provided to tpe as my representative. — — PAYNlEIrI-.0 — <br /> ';YPEofSER49aREQUESTEC. Pool Improvements — Plumbing and Gutters�,� — <br /> NOV 1 6 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ----�---- -- EMPLOYEE#: �?� DATE) _1 r <br /> A�:cePtEo By, l�J�[ V�1 � � --- �E. 1 <br /> __...... _ ENIPLOYpE�: <br /> ASSiGNFt)til: <br /> �PIE: <br /> SERVICE Geek; S Z <br /> pServiao Cnrnfsi <br /> atty etod (If already complete \ <br /> ount <br /> — mPPay_-rm1.eYrt Date <br /> aid <br /> Rcp VCG(13y- <br /> Check e- <br /> paymentType ✓ Invoice# <br /> --_ <br /> ---- <br /> SR FORM(C,oICQn Rod) <br /> EWU 0.02-025 <br />