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03/07/2009 19:48 2094654988 HMC PAGE 02/06 <br /> SAN JOAQUIN IOUNTY,ENVIlkON-MENTAL'19]FALTII Ar-TMIT, <br /> +,.....,,. SJl'rRM 1r1S:Fi(�UST ; <br /> �— FACILITY(D# SERVICE REQUEST* <br /> Type of BtiiIrlens Or Pro �J <br /> .. <br /> OMER 11)PiRRATOR ViC ewectcitE EE WNG A <br /> FAM NA,I�E 76„Lodi"COUNTRYSIDE" <br /> SttEADnA " 1A971 N 114 <br /> SS Lodi, A 95240 <br /> _ a d <br /> HOME Or KNIl.INt3 ADDRESS (if D;&.-rent from Site Address) <br /> Nu <br /> $TATS ZIP <br /> cny <br /> LA <br /> Exr. p pN ND i sis APFUCA11ON# <br /> Pio <br /> i 1 't 2091948-1684 <br /> m iRrar.> r.. ,_•. -•�•, _ F.%T. 130S DISMOT- LOCA�r CODE- <br /> A I .� <br /> _ j- <br /> CONTRACTOR SERVICE R.EQUESTOR <br /> Er <br /> RFQur=s-'roR Cart W Henderson C14ECK if APAXPAROM <br /> T. <br /> BuslNes s: lAats HMC-Henderson Maint Cc 1 EX(209)467-7573 <br /> Home or�AP;w"ADDRESS (20 <br /> PO Box 31325 - Stockton,CA 95213 ADDRESS (209 465-498$ <br /> CrrY STATE Zr <br /> R .L ''r; ❑ T. t, the undersigned property or!business ower, operator (* author!zed amont of same, <br /> acknow),,4ge that all site and/or project speci,ac E oNMT:2VTA.L REA.r Tm ARTmgw hentrty chmies nssociatc4 with this Mimi: <br /> or aetivil;p wjq be billed to me or,my business as idendfled on this form. <br /> i<also cc,tlyfy that I have prepared this application and that tate work to be performed will be done in accordance with all SAN JOAQTJiN <br /> CouKT1 Ordinance Codas,Standards.SXA'TE and FMERAL laws, <br /> APPLICANT'S SIEGNA'lME: a____ DACE; f/e� <br /> PROMPT",;/BlTBtIVE. ❑ •3Z1�C'R00A./MANAGE�R® oTLvRAa A,GR CCIM4-A,Ac :t0-2, <br /> If APPLICAW is not rite&LUNG_ RTy proof of author aden ea is required Title <br /> ,s► t� i .ATION'T'A T Sls TN OPJ AiTLW,When applicable,1,the owner or operator of die property located at the <br /> ave Cite a4dress, hereby authori7�e the release of any axed all recuits, grotechnical data acid/or envirornncruvsite assessment <br /> infenwl•;.m t)the SAN JoAQt)jN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as sobrt A. it is available and at the.same time it is <br /> provide4lo me or liy'reptmerltative, ; <br /> TYPE OF 3T-WcE RgQuesTED: 4BECEUGO <br /> commmild <br /> 'Insiall Healy Clean Air Separator[CAS]with existing Healy VAC installation- OCT 2 11008 <br /> AkLY[CAS] <br /> SAN JOAQUIN OQUN Y <br /> ENVU10t4MMAL <br /> HEALTH DePARTMEPU <br /> ACCEPTIRT)BY; EARFLOYEE#: 1Y DAM ® � <br /> AssioNAP To: EMPLOYEE#: ,, DATE <br /> Date 3H.t' ce Completed (if already completed}, $ERViCEC�E: { P 1 E: 1Z3 D 0 <br /> Fee Ars;int_. 51 AretOUpt Paltl �'S• r� L1. Payment Date D <br /> Invoice# Check 9 � Received By: <br /> Paymei-ill,Tyke ' — <br /> EHD 45•g9-023 SR FORM(Golden Rod) <br /> RSV1812011/17/2003 <br />