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Nov 07 14 03:03p Elite IV Contactors 12094616342 SAN JOAQU`F0OUNTY ENVIRONMENTAL HEALTBO.PARTMENT SERVICE REQUEST Type of Business or Property Wk r'`1`j ` FACILITY ID # .� OWNER / OPERATOR EMPLOYEE #: city ASSIGNED TO: i Zip Code FACILITY NAME I •luo Worm,�4 zip SITE ADDRESS 2' /L IPPLICATION # � �'`t�o (o)v .ICT LOCATION CODE Street Number r f Invoice # Street Name G# epti HOME or MAluNG ADDRESS (If Different from Site Address) 4)(0 Enkiriifl"ie, sifs Street Number CITY STATE P14ONE#1 EXT. APN # LAND U: (&0 1 04- b( -()-i3 PHONE#2 EXT. BOS DI ( ) 0 IE 31 0 P.3 SERVICE REQU ST # Wk r'`1`j ` r.' CHECK if BILLING ADDRESS ACCEPTED BY: EMPLOYEE #: city ASSIGNED TO: i Zip Code Street Name zip ,/ r IPPLICATION # Fee Amount: .ICT LOCATION CODE - ,, CONTRACTOR / SERVICE REQUE!w--'1 OR REQUESTOR ` � ? CHECK if BILLING ADORES$ BUSINESS NAME ; i INE # EXT• i _ I, HoME or MAILING ADDRESS f x# 2,955 b-,witkinm) CITYLtr STATE r ZIP BiILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, o rerator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT ho rly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that 1 have prepared this application and that the work to be performed will be: d ne in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:i a. �.3 .TE: �t�rrl �'�u�t PROPERTY/ BUSINESS OWNER© OPERATOR/ NLkNACER I3 OTHER AUTHORIZED ACEI I NL— J�j y (�c fi W. If APPLICANT is not the BILLING PARTY, proof of authorf; ation to sign is regvit d I Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner is r perator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical dat and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a: it is available and at the same time it is provided to me or my representative.t – _ - pro. `ymn.. i3 G�i� '' t, , TYPE OF SERV D:, •, 1 T Wk r'`1`j ` r.' COMMENTs: RECEIVED Nov 10 2014 sj N.FOAQUIN COUNTY EMMRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: ASSIGNED TO: i EMPLOYEE #: Date Service Completed (if already c pteted): SERVICE CODr Fee Amount: Amount PW 37D. ! d D Pa: Payment Type - Invoice # G# epti (o Nov 0 7 2014 4, DATE: DATE: PIE: 'Zt V tent Date11 l d %O 0 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/1712003