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Feb 12 14 09:41a _ Elite IV Contactors _ 12094616342 p.2 SAN .TOA(, -,N COUNTY Type of Business or Property OTENTAL HEA. REQUEST .�— FACILITY ID # OWNER 1 OPERATOR ELJ -PAYMENT RECEIVED JAN 8 12014 ITA I SAN JOAQUIN .COUNTY FNT HF.A1. t PIq r (l(r city_ Zip Code FAciuTY NAME Zip r SITE ADDRESS ISTRICT b/L LOCATION CODE ACCEPTED BY: Sheet Number Dire flon ASSIGNED TO: tr-ft Name HOME or MAILING ADDRESS (if Different from Site Address) EMPLOYEE #: Date Service Completed (If already completed): Stree Number SERVICI CITY STA PHONE #1 ExT. { ) APN# LAN PHONE #2 ExT, Invoice # BO: CONTRACTOR / SERVICE REQUESTOR t rBUSINEss NAME i..- , ' i ! , '.y ': `! { r -,- ;7 _i DEPARTMENT SERVICE REQUEST # CHECK If BILLING ADDRESS ❑ ELJ -PAYMENT RECEIVED JAN 8 12014 ITA I SAN JOAQUIN .COUNTY FNT HF.A1. t PIq r (l(r city_ Zip Code Feet Name Zip r SE APPLICATION # ISTRICT b/L LOCATION CODE UE )TOR CHECK if BLLUNG ADDRESS PHONE # HOME or MAILING ADDRESS _ FAx# CITY _ STAI ,; /I zip BILLING ACKNOWLEDGEMENT: I, the undersigned property or business ow:ne , operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMEN 1 iurly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed wi' l a done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: -,y i„ ? _ DATE: PROPERTY / BUSINESS OWNER ElOPERATOR ! MANAGER ❑ OTHER AUTHORIZE:) aENT'd If APPLICANT is not the BILLING PARTY, proof of authorization to sign is rt wired Ttrte AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owr.e or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechni:.a data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT asso- a as it is available and at the same time it is provided to me or my representative. TYPE me SERVICE REQUESTED' COMMENTS: ELJ -PAYMENT RECEIVED JAN 8 12014 ITA I SAN JOAQUIN .COUNTY FNT HF.A1. t PIq r (l(r REGER )DE: r I Payment Date iteceived By: _ FES ] L' ACCEPTED BY: hNIRM ASSIGNED TO: L}�� L, EMPLOYEE #: Date Service Completed (If already completed): SERVICI Fee Amount: "3Ir. Amount Pald - Payment Type Invoice # Check # Jr� ; E:Ljr, 40 „' n,� SR FORM (Golden Rod) ELJ -PAYMENT RECEIVED JAN 8 12014 ITA I SAN JOAQUIN .COUNTY FNT HF.A1. t PIq r (l(r DATE: )DE: r I Payment Date iteceived By: _ E:Ljr, 40 „' n,� SR FORM (Golden Rod)