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JRSAN JOAQUI40 V r, VIRONMENTAL HEALT lEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />0/ 77/ <br />SERVICE REQUEST # <br />Sre-oo(02.4,02 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Pacific Commons <br />SITE ADDRESS 504 <br />Street Number Direction <br />Northbank Court <br />Street Name <br />Stockton <br />City <br />95207 <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 Exr. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , Tim Hempleman CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME Hempleman's Pool Cures PHONE # <br />( 209 ) <br />Err. <br />614-6385 <br />HOME or MAILING ADDRESS 11749 Sawyer Ave Fax # <br />( 209 ) 847-3a05 <br />Crry Oakdale STATE CA ZIP 95361 <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 anc laws... - <br />APPLICANT'S SIGNATURE: DATE: 12-15-2010 <br />e. <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT g.] 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 time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: VGB Compliance <br />COMMENTS: PAYMENT RECEIVED <br />MAI 26 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL _ <br />HEAL-n-I DEPARTMEN1 <br />ACCEPTED BY: t_seve EMPLOYEE #: qe ST DATE: 572- /17. ce <br />ASSIGNED TO: PED/214-2-44- EMPLOYEE #: eo 2...( 3 DATE: 57'2.6 4, <br />Date Service Completed (if already completed): SERVICE CODE: 52- 2- P I E: 3 662 _ <br />Fee Amount: .,2 /..W,0 9 Amount Paid 4 tJ- Payment Date S I 2.4./ I. \ <br />Payment Type c t... . Invoice # Check # Received By:(V.,_