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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Vacant Commercial Former antique shop <br />FACILITY ID # <br />.— ,, ,_ <br />2-1-- S 7) <br />SERVICE REQUEST it <br />S 1(1- CC -? <br />OWNER/OPERATOR <br />NATHANIEL PAPADAKIS <br />CHE CK if BILLING ADDRESSX <br />FACILITY NAME <br />NA FORMER 'AAA GOLD, JEWELRY, ANTIQUES, COINS' <br />SITE ADDRESS <br />18 <br />E <br />Direction <br />11th Street <br />Street Name <br />f <br />Tracy 96376 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />2602 Street Number <br />271h Avenue West <br />Street Name <br />CITY SEATTLE STATE WA ZIP 98199 <br />PHONE #1 Ex-r, <br />( 206 )779-4877 <br />APR # <br />235-171-03 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( I <br />DOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQIJESTOR <br />REQUESTOR JOHN WINKLER CHECK If BILLING ADDRESS X <br />BUSINESS NAME FULCRUM RESOURCES ENVIRONMENTAL PHONE it <br />( 800 ) 385-7105 <br />EXT. <br />HOME or MAILING ADDRESS 617 SOUTH IVY AVENUE Fax It <br />( 800 ) 585-7126 <br />CITY MONROVIA STATE CA ZIP 91016 <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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />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 />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />3/07 <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El <br />APPLICANT'S SIGNATURE: <br />PROPERTY I BUSINESS OWNER X <br />DATE: <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tile <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: (.;,),,, r Lk -,., \ -,- I," ( e7 <br />COMMENTS: <br />ACCEPTED By: I <br />EMPLOYEE #: Ct) L j DATE: -?, 3 I <br />ASSIGNED TO: L,41,- <br />o <br />$.-L-,,----\\ <br />EMPLOYEE #: 00 , z, I DATE: ,?.., ( ,) I/ 1 -7 <br />Date Service Completed (If already cc6pleted): SERVICE Coot: (.-"..,'" 2:7, PI E: 2y1t23 <br />Fee Amount: Amount Paid 4 , <br />_ <br />)1 -) Payment Date )/?;3 i 2_0 ‘ 1 <br />Payment Type Invoice # Check # } ',',1 ,:t L I Received By: <br />SR FORM (Golden Rod) END 48-02-025 <br />07/17/08