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i SAN JOAQUVCOUNTY ENVIRONMENTAL HEALTHPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1F400443vo 5ROC1667a-7 <br /> OWNER/OPERATOR Vic CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME 76- Lodi "COUNTRYSIDE" <br /> SITE ADDRESS 14971 N Hw88 Lodi, A 95240 <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 ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) [209] 948-1684 a(P3 1425 <br /> PHONE#2 ExT. 11 BOS DISTRICT LOCATION CODE�f <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl W Henderson CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> HMC- Henderson Maint Co (209)467-7573 <br /> HOME or MAILING ADDRESS PO Box 31325 - Stockton, CA 95213 FAx# <br /> ( 209 ) 465-4988 <br /> CITY STATE ZIP <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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQIJIN <br /> COUNTY Ordinance Codes,.Standards,STATE and FEDERAL laws. �{ <br /> APPLICANT'S SIGNATURE: f _ ��� DATE: 16 -� C1 <br /> PROPERTY/BUSINESS OR:NER❑ ?OPERATOR/NIXNAGER ❑ OTHER APTHORIZED AGENT® n- R A C t 0 12— <br /> If APPLICANT is not the BILLIVGPART ,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: I _ 0 <br /> COMMENTS: <br /> Install Healy Clean Air Separator[CAS]with existing Healy VAC installation. O C T 2 1 2008 <br /> H EALY [CAS] <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: �/ E' DATE: 0/-Z-7/ 0-Z 0 <br /> ASSIGNED TO: / 1 l EMPLOYEE#: DATE: <br /> DATE: o <br /> Date Service Completed (if already completed): SERVICE CODE: l PIE: <br /> Fee Amount: /� Amount Paid rP 31 S. Payment Date C) 8' <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />