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n a, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Concrete Manfacture '' <br /> OWNER/OPERATOR <br /> John Bertao CHECK I$BILLING ADDRESS <br /> FACILITY NAME t9 <br /> v"- 6"""1 <br /> SITEADDRESS, <br /> Street Number Direction Street Name ity } <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 969-3132 _ <br /> PHONE#2 EXT. BOS DISTRICT rI "''7N CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> Elite IV Contractors (209) 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx# 461-6342 <br /> ( ) <br /> CITY Stockton STATE CA ZIP 95206 <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 <br /> or 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: Ga4A'4�- W4&41 DATE: 3/19/2015 <br /> ff <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 119 Office Manager <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. pq YAgg— <br /> TYPE OF SERVICE REQUESTED: Replace Diesel STP Relay AA. CEN <br /> COMMENTS: SA <br /> Hyl aF t 7Y <br /> ACCEPTED BY: d��& EMPLOYEE#: DATE: .� <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P I E: . <br /> Fee Amount: Amount Pai 0 Payment Date <br /> Payment Type Invoice# C e k# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 e� <br />