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� P <br /> �-- CX (�)j1� A OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MAR 0 5 2009 SERVICE,REQUEST <br /> Type of&isiness or Property FACILITY ID# SERVICE REQUEST# <br /> RPA4,., <br /> OWNER/OPERATOR , �.;a � <br /> Vic CHECK If AIlUNG ADDRESS <br /> FACIUTrNt,ME 76-Lodi"COUNTRYSIDE" <br /> SITE ADDRESS 14971 NH 88 Lodi, A 95240 <br /> Street Number Direet on Street Nam city Zip Code <br /> HOME Or I11AILING ADDRESS (If Different from Site Address) <br /> Stre -StreetName <br /> Cin STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( D [ <br /> 2091948-1684 R( 21 <br /> 02-5 <br /> PHONE42 - --- ExT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Carl W Henderson CHECKifAtLLiNGADORESS <br /> BUSINES!i.NAME PHONE# Ext. <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 /> IILLIP G ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowl.dge 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 et rtify that I have prepared this application and that the work to be perfortnr d will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Lodes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> PROPF,R'N/BUSINESS OWNERO ;OPERATOR/MANAGER O OTHER AUTHORIZED AGENT �C,;i �X h C t 0 J� <br /> IJAPPLICANT 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 sate address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> informal ion to the SAN JOAQUIN COUNTY EATVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provideato me or my representative. <br /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: i Q / <br /> COMMENT!: <br /> Install Healy Clean Air Separator[CAS]with existing Healy VAC installation- <br /> HEALY[CAS1 OCT 2 1 200$ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTEMPLOYEE#: DATE: 0 2. Q <br /> ASSIGNED TO: /`L i EMPLOYEE#: t DATE: O <br /> Sc Nice Completed (if already compieted): SERVICE CODE: ( --T- <br /> Date : IZ3 t9 t- <br /> Fee Amount: 3,P5 Amount Paid �]�, v l0 Payment Date 10 a` <br /> Payment Type Invoice# Check# '� Received By: <br /> 'i <br /> EHD 48-102-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Ali <br />