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SAN 0A00IN G IJIN T Y L NVIROMNIEN I 'AL HEALTH DEPARTMENT <br /> 8JE�VGL G? LQZU 15 V� <br /> Type of Business or Pronerty f ACIIITY IDs? SERVICE REQUEST # <br /> OWNER / OPERATOR Thomas Tilly CHECK If BILLING ADDRESS I--I <br /> FACILITY NAME AG Spanos Aviation Dept <br /> SITE ADDRESS 4800 S Airport Way Stockton 95206 <br /> Street Number Direction I Street Name Cit _ Zip 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 /> ( 209) 993 -2481 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRA CTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK IfBILLING ADDRESS LCK <br /> BUSINESS NAME Elite IV Contractors PHY6r9#461 -6337 Ext. <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 aa�ientified on this form , <br /> also certify that I have prepared this ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST TE a f d `FEDERAL laws . <br /> APPLICANT' S SIGNATURE : .�U (�t� hl�el <br /> tL DATE : 2/28/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 1Z 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 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 provided t0 me Or <br /> my representative . t' <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : EI VAC <br /> MAR ® 3 2 <br /> SAN ®22 <br /> HEA TN PMEN��Nry <br /> ACCEPTED BY : 1 \ / Q�/��f EMPLOYEE #: DATE : <br /> ASSIGNED TO : a � EMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed) . .� SERVICE CODE: �GT� �J/i PI E 200k <br /> Fee Amount: ' Amount Paid Payment Date <br /> i 3 <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/17/08 <br />