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Apr 04 02 12: 18p Elite v Contractors Inc 2094616342 p. 5 <br /> ,.,AiN JUAQU OUNTY ENVIRONMENTAL UEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Grams -�tcm <br /> OWNER/OPERATOR• <br /> CNECK)f BILtINti ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS `;( ((// lA�� .{{33yy <br /> '5tre�Namber Directional SIreName Zi Code <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 /> (0z0) 3(c%--1-53-jo <br /> PHONE#2 EXT, SOS DISTRICT LOCATION CODE <br /> d �) �55• <br /> CONTRACTOR/ SERVICE REQUEESTOR'. <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME �l PHONE# ET <br /> VGA ' <br /> ¢, 1 +1� r- 9 61-" 6,337 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATECA ZIP <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: 1 r ' DATE: $ <br /> PROPERTYIBUSINESS OwNER❑ OPERATOR/MANAGER ❑ OTHER AuTuoRIzEDAGENT;K e-/'L2L-,? Lcn^ JV-k-,r- <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Till e <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By <br /> EHD48-02-025 `'±Sf tStRIA``(ao[dlnl2ixSj.'t <br /> REVISED 11/17/2003 <br />