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Oct 29 14 03: 04p Elite IV Contactors 12094616342 p. 3 <br /> SAN JOAQ*COUNTY ENVIRONMENTAL HEAL'OEPARTMENT <br /> •t SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rA 000 Mos 5 00 "�0 � <br /> OWNER!OPERATqR <br /> _ CHECK If BILLING ADIMESS 13 <br /> FAcarrYNAME <br /> SITE ADDRESS <br /> 1�+ I'' W��(l,•,. !I+' Q \ Ci <br /> Iv Strep Nu ber %Ye Narnr�e�' t e`✓ .I . V��.7EI IC��1 iJ 1adeo <br /> HOME Or MAILING ADDRESS (N Different from Site Address) <br /> CITY Street NumCer _ Street Nenia <br /> STATI ZIP <br /> PHONE 91 ExT• APN# u1N] '.SE APPLICATION# <br /> [ I X175j l4G Del, <br /> ZG — <br /> PHONE92 Exr. <br /> 1!'I STRICT LOCATION CODE <br /> - <br /> CONTRACTOR! SERVICE REQUI, ;TOR <br /> REQl1ESTORI{/— — - <br /> •l - I (1 cnko r4c(s CHECK If BILLING ADDRESS <br /> BUSINESS NAME F _I Pd E(Er- <br /> HOME or MAILING ADDRESS <br /> G'� � FAx# <br /> CnYi\Ih,('kn l STA rE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business own a operator or authorized agent of some, <br /> acknowledge that all site and lor project specific ENVIRONMENTAL HEALTH DEPARTMENr ourly 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 appe ' On and that the work to be p ormed will b done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TATE aDd FEDERAL la <br /> APPLICANT'S SIGNATURE: �lC A " JIt- cl DATE: JB v`� <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED A, ENT <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is req. iced rice <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the owner r operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical , ata and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as sOOr 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: �q y <br /> CL-IV^/T <br /> OppEo <br /> '92014 <br /> ty�ogp <br /> _ '"+GM'IgON/IyC <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> aLL r� <br /> Date Service Completed (if already completed): SMMCEC{o I� p 1 E: 73 0$ <br /> Fee Amount 7 c10 Amount Paid jp — P. pment Date p/ j <br /> Payment Type IS Invoice# Check .I} ! ,?3Z.;, <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 OCT (�$q F r y �¢(Golden Rod) <br /> ENVIRONMENTAL HEALTH <br /> "i1 <br />