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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH.A-RTMENT <br /> SERVICE REQUEST EX �-j j ni <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF 0056-72—7 <br /> OWNER/.OPERATOR Minna Sandhu CHECK if BILLING ADDRESS <br /> FACILITY NAME 76- Lodi 'COUNTRYSIDE' ---- ' <br /> SITE ADDRESS 14971 N Hwy 88 Lodi 95240 <br /> Street Number I Direction I Street Name city Zio 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 /> ( ► 209-368-4972 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson <br /> CHECK if BILLING ADDRESS 91 <br /> BUSINESS NAME PHONE# EXT. <br /> HMC - Henderson Maintenance Company 209 467-7573 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31325 ( 209 ) 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <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 ENVIRONMEN IAI. HEALTH Di-TA RrrMENT 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQuIN <br /> COUN rY Ordinance('odes,Standards, STATF.and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C�� �- Hl�< DATE: <br /> PROPERT1 /BUSINESS OWNER❑ OPERATOR/MANAGFIR ❑ OTHER AUTHORIZED AGENT® Contractor <br /> lf.11'Pl.1c,INl'is not the B/1,/./;VG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 HFAL,ril DEPARTMIAT 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: Piping Retrofit <br /> COMMENTS: Defective MLLD found and replaced during Annual Monitor Certification testing with Aris(EHD)on site <br /> A <br /> �r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 4/29/09 SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />