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SAN JOAQUIt, OUNTY ENVIRONMENTAL HEALTH . —PARTMENT <br /> SERVICE REQUEST 101 5 3 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF ( 7v9- �, 7 �' <br /> OWNER/OPERATOR Euginia CHECK if BILLING ADDRESS <br /> FACILITY NAME J&L Market <br /> SITE ADDRESS 8115S EI Dorado St French Camp 95231 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ► 982-0897 I t �(,�(,1 3 <br /> PHONE#2 EXT. BOS DISTRICT C .3 LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> APEC 209 943-3000 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 55105 (209 ) 943-3003 <br /> CITY Stockton STATE CA Zip 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that 1 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 /> APPLICANT'S SIGNATURE: C4-,i - tl�'�—� DATE: 6/3/11 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Techninian <br /> ifAPPLICANT is not the BILL/NG 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: 1/ RECEIVED <br /> COMMENTS: JUN — 6 2011 <br /> Replaced ATG Keyboard (indicator lamps were inoperable) SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEp,LTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 'NY-7 <br /> 'J�"7 Y-3 DATE: <br /> DATE: / „ I <br /> 4A2-1l <br /> ASSIGNED TO: ` �` EMPLOYEE#: ` DATE: <br /> Date Service Completed (if already completed): 6/3/11 SERVICE CODE: j �� P I E: a <br /> Fee Amount: (f,� wo Amount Paid 3 Payment Date b <br /> Payment Type Invoice# Check# 2 ` l Recei ed y: li\4-- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />