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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVI ' E REQUEST # <br /> OWNER / OPERATOR <br /> Raij Amba CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Thornton 76 <br /> SITE ADDRESS 8606 Thornton Rd Stockton Ca <br /> Street NumberDirection Street Name c1tv Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, AP # LAND USE APPLICATION # <br /> ( 408 ) 593-3910 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT' <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 /> 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 . 1 <br /> APPLICANT' S SIGNATURE : � DATE : �� / � <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Assistant <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 ass%sment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time it ed to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : 3 <br /> 410, 4?019 <br /> A A )v71, <br /> RTMFNT <br /> ACCEPTED BY : t Y� EMPLOYEE # : DATE : L:? / <br /> ASSIGNED TO : <br /> EMPLOYEE � I✓ t DATE: � / <br /> Date Service Completed ( if already completed ) : SERVICE CODE : q , PI E: <br /> Fee Amount:4 tro Amount Paid � �(j Payment Date g,300 <br /> Payment Type �j� Invoice # Check # S'� 2 Receivdd By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />