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Apr 04 06 <br />i�- <br />l�tJ <br />03:11p Elite Iv Contractors Inc 2094642 <br />OA1N J VAY 1. V u 1 1 Y V 1V V <br />V IK1N1VIF IN 1 AL IILAI 1 YA1tI All iN 1 <br />4{y g - 3y - SERVICE REQUEST <br />p.1 <br />Type of B ess or Property <br />FACILITY ID # <br />P N � �` <br />SERVICE REQUEST # <br />F� #` <br />CITY STATE ZIP <br />y V. . / <br />EMPLOYEE #: <br />DATE: <br />OWNER/ ERAT <br />SERVICE CODE: <br />CHECK if BILLING ADDRESS <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />FACILrrr NAME -�. �, r' ►% <br />Invoice # <br />Check # <br />SITE ADDRESS <br />Street Num e? Di ec n <br />Street Name C� <br />de <br />HOME Or MAILIN ADDRESS (If Different from Site Address) <br />Street Number <br />) <br />/ "' 4 1 L "—St�t <br />t� <br />Nam �' <br />CITY � �A CI � � ��� � <br />JL <br />I`STATE �. <br />)ZIP <br />PH0NE#1 EXT* <br />APN# <br />LAND USE APPLICATION# <br />PHONE #TExT <br />BOS DISTRICT <br />LOCATION CODE: <br />1 ` 06 CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO J ! j' /L CHECK If BILLING ADDRESS <br />!/ ( <br />BUSINESS NAME L� � ! <br />� , (J. <br />P N � �` <br />HOME or MAILING ADDRESS �' <br />F� #` <br />CITY STATE ZIP <br />y V. . / <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 />I also certify that 1 have prepared ' application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standa ds, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: � ' DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT-oe, , <br />IfAPPLICANT 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 <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 JOAQUTN 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: <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Gold' 'Rod) <br />' <br />