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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 />P ACT 2--S <br />SERVICE REQUEST # <br />S R- co -3 ,,-4 7 . <br />OWNER/OPERATOR <br />NATHANIEL PAPADAKIS CHECK if BILLING ADORESSX <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 Tracy 95376 <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />2502 Street Number <br />27th Avenue West <br />Street Name <br />CITY SEATTLE STATE WA ZIP 98199 <br />PH0NE#1 EXT. <br />( 206 )779.4877 <br />APN it <br />235-171-03 <br />LAND USE APPLICATION if <br />PHONE #2 EXT. <br />( I <br />) BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR JOHN WINKLER CHECK if BILLING ADDRESS X <br />BUSINESS NAME FULCRUM RESOURCES ENVIRONMENTAL PHONE # <br />( 800 ) <br />EXT. <br />385-7105 <br />HOME or MAILING ADDRESS 517 SOUTH IVY AVENUE FAX # <br />( 800 ) 385-7126 <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 />I 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 />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER X OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />DATE: <br /> 305p7 <br />Title If APPLICANT /S not the BILLING PARTY proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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: (../Ut.1; k,.. r <br />COMMENTS: <br />ACCEPTED BY: i ,..„ A <br />EMPLOYEE #: DATE: 2. /2_ a <br />ASSIGNED TO: <br />L- <br />EMPLOYEE #: oc ,,z, i DATE <br />2- ( 2--‘) i I 'I <br />Date Service Completed (if alreadpleted): SERVICE COOE: c2:/ PIE: 21,03 <br />Fee Amount: Amount Paid $ /A 1 -) Payment Date 31./23 I 2_0 1 <br />Payment Type Invoice # Check # Ns LI Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)