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SAN JOAQ#I*NTY ENVIRONMENTAL REALTOWMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> AG Spanos Jet Center <br /> OWNER/OPERATOR <br /> Tara Hagopian . CHECK if BILLING ADORESS� <br /> T <br /> FACILITY NAME AG Spanos Jet Center "ee' ve6 I _:_, ; '• <br /> SITE <br /> 4800ADDRESS S Airport Way Stockton <br /> Street Number Direction Street Name cit MAY Q .de <br /> HOME or MAILING ADDRESS (If Different from Site Address) / <br /> Street Number at <br /> CITY STATE "ZIP Y,,.,; <br /> PHONE#1 En. APN# LAND USE APPLICATION If <br /> ( 209) 993-2481 <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHON # E".26461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr F 20 <br /> ( 91461-6342 <br /> CITY Stockton STATE CA zip 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 <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 ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Nva-1, DATE-:: 5/9/2016 <br /> ❑ It <br /> PROPERTY/BUSINESS OWNEROPERATOR/ OTHER AUTHORIZED AGENT Office Assistant <br /> J.fAPPLICANT i8 not the BlLLLNG 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. <br /> TYPE OF SERVICE REQUESTED: Cold Start, replace diesel flex line and stp sump, and instal - T <br /> COMMENTS: <br /> MAY 10 2016 <br /> SAN JOAQUIN COUNTY <br /> EN VIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: / <br /> EMPLOYEE DATE:AJ •b <br /> Date Service Completed (if already completed): SERVICE CODE: 19) IE: <br /> Foe Amount: 5 ( Amount Paid 3�d , pp Payment Date Jf- t <br /> Payment Type V(S p` Invoice# Cheek-#T 1 1010 '9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />