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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # z SERVICE REQUEST # <br /> 7b Do ' 1 (; (4)r <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Thomas <br /> FACILITY NAME AG Spanos Jet Center <br /> SITE ADDRESS 48100 reet Number DS� tlo� Airport Way Street Name Stockton 95206ty Z(n e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Sfreet Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209 993 -2481 '1 �1 2 ~ <br /> PHONE #2 EXT. BOS DISTRICT7,)T�]FLOCTATTI.,ONPOIDE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors46L61137 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX # <br /> ( 209) 461 - 6342 <br /> CITY Stockton STATE Ca ZIP 95205 <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 : W(,rl ae4y DATE : /0� � f/ <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ® nffir.P Assigtnnt <br /> If APPLICANT 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is provld �nfte Or <br /> my representative. I* <br /> TYPE OF SERVICE REQUESTED : US7 elt <br /> COMMENTS : <br /> 20 <br /> S�VpAQUIN <br /> CO TY <br /> OEp'� 4 ME <br /> T <br /> ACCEPTED BY: �� v4err.�-� EMPLOYEE # : ALDATE: <br /> ASSIGNED TO : S � /VZ4* EMPLOYEE #: / / DATE : /a <br /> Date Service Completed (If already completed ) : SERVICE CODE: P I E: d <br /> Fee Amount: jq5& ov Amount Pai 41.6 Oo Payment Date q <br /> Payment Type Invoice # Check # Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />