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APPLICANT'S SIGNATURE: Ysd— <br />OTHER AUTHORIZED AGENT al Accounts Receivable Mgr. <br />DATE: )Z- 6) -I <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 <br />SAN JOAQU_ COUNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Apartments <br />FACILITY ID # <br />_: (70 <br />SERVICE REQUEST # <br />-K-g-- 00(f 7 45' <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Tracy Park Apartments <br />SITE ADDRESS <br />2800 Street Number <br />N. <br />Direction <br />Tracy Blvd. <br />Street Name <br />Tracy <br />City <br />95376 <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 />( 209) 836-5000 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Debra Fagundes CHECK if BILLING ADDRESSO <br />BUSINESS NAME Burkett's Pool Plastering, Inc. PHONE # <br />( 209 ) 599-3317 <br />EXT. <br />HOME or MAILING ADDRESS P.O. Box 938 <br />Fax # <br />( 209 ) 599-1701 <br />CITY Salida STATE Ca Zip 95368 <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 />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: --POOL (S/A- ,--. 71.1-f el1e-Ei--1(6 4 t_ A -A--"-, C44.6-ce:__ <br />COMMENTS: <br />Verify new VGB covers installed in Spa. Paramount SDX 10" round (sumpless) covers installed on oalEN <br />drain and split equalizer lines. <br />JAN -7 20 <br />SA JOAQUIN <br />IVE <br />CO <br />ACCEPTED BY: 04:4 ucc eozt_ EMPLOYEE #: 0 ., 2..ri DATE: <br />V ONMtNrA <br />EPARTM <br />ASSIGNED TO: d EMPLOYEE #: 6 2i3 DATE: 7/// <br />Date Service Completed (if already completed): SERVICE CODE: S-2 2.__ 1 E: <br />( <br />2 60 2- <br />Fee Amount: 4 2 4 4 - 7 - e-r j Amount Paid LA Lk -- <br />Payment Date <br />\( 7/ " --- Payment Type , Invoice # Check # Lk 5 ,-2_ tpi _k Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />O <br /> \ 1101' Nrt <br />'! <br />SR FORM (Golden Rod) <br />11 <br />NTy <br />NT