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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property r� FACILITY ID tl SERVICE REQUEST # <br /> Aviation Fueling y fco � 3 j <br /> OWNER / OPERATOR <br /> Thomas CHECK If BILLING ADDRESS <br /> FACILITY NAME AG Spanos Aviation Dept <br /> sIrEADaREss4800 Airport Way t Stockton 95206 <br /> streot Nu ber Irreectlo Star lame I Cit <br /> 21 CaBrt' <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �e' • r <br /> Street Number Street Name �� V9h <br /> CITY STATE ZIP y� ((JJ <br /> PHONE#t EXT, MIN III <br /> APN # LAND USE APPLICATION # 2023 <br /> 2023 <br /> (209) 993 -2481 V OAQ0 N c <br /> H RON ME Ty <br /> PHONE #2 ExT. <br /> DOS DISTRICT LOCATION CODE <br /> ( 1 NT <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECKIf ILLINGADDR SS � <br /> BUSINESS NAME Elite IV Contractors NONE # ExT. <br /> 209 467 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wgwarn Dr { ) <br /> CITY Stockton STATE CA ZIP <br /> 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 worts to be performed will be done In accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, VAy and FEDERAL la s. <br /> I <br /> APPLICANT'S SIGNATURE : 1y- DATE: 11S <br /> PROPERTY / BUSINESS OWNER D OPERATOFtJM, .ANAGER T OTHER AUTHORIZED AGENT � - AI/ fa7rh .� site «rII�, QS� <br /> if APPLICANT fs not the $ILLiNG PARTY proof of aF . uthorization to sign IS required Title r— <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results, ,geotechnlcal data and/or envlronmental/site assessment Information <br /> to. the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and of the same time it Is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : �4 <br /> COMMENTS: <br /> i <br /> t <br /> ACCEPTED BY: . \ EMPLOYEE #: DATE; <br /> ASSIGNED T0 : v ° EMPLOYEE # ; DATE: 3v <br /> Date Service Completed (If already completed): ! SERVICE CODE; ,/�� �� 9� P /E; <br /> Fee Amount: AmountPaiPayment Date <br /> Payment Type Invoice # Check tlSt'o y oS� Received By: <br /> DHD 48 02-025 SR FORM (Golden Rod) <br /> 67/17/08 <br />