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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> S'TX00 5S' <br /> OWNER / OPERATOR <br /> Robert CHECK if BILLING ADDRESS <br /> FACILITY NAME Estes Express Lines <br /> SITE ADDRESS 7611 S Airport Way Stockton 95206 <br /> Stroet Number Direction Street Name I c1tv Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Streot Number Street Nama <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 982-1841 <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Megan Mitchell <br /> PHONE # ExT' <br /> BUSINESS NAME <br /> Elite IV Contractors 209 461 -6337 <br /> HOME Or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 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: �`2 DATE : <br /> f Offir , <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / ANAGER ❑ OTHER AUTHORIZED AGENT IJ ce Assistant <br /> /f 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS prom'ded to me or <br /> my representative . IJW <br /> TYPE OF SERVICE REQUESTED: f 0*4 %O <br /> COMMENTS: <br /> kt 0 <br /> sAN J <br /> 0 <br /> A <br /> Q <br /> H P F N CT FF/trV/RO UN /IV CO <br /> UN <br /> .q M D RN?'At <br /> ART <br /> M <br /> F <br /> NT <br /> ACCEPTED BY: td j ���� EMPLOYEE #: ISI DATE: . 7 <br /> ASSIGNED TO : s v EMPLOYEE #: On DATE; 3 <br /> Date Service Completed (if already completed) : SERVICE CODE : P I E:�? <br /> Fee Amount: 5� Amount Paid v� Payment Date �S <br /> Payment Type Invoice # Check # Rec ived By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />