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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail 7 sv, 001 In (-i3-Z, <br /> OWNER i OPERATOR <br /> Wes Parkson CHECK If BILLING ADDRESS <br /> FACILITY NAME Hammer 1-5 Investments Inc <br /> SITEADDRESS 3250 W lHammerl-ane Stockton 95209 <br /> Street Number e Stree-tNAML-- CIty in Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> er St <br /> Street Numbreet Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 } 662-4452 <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Megan M CHECK If BILLING ADDRESS® <br /> BUSINESS NAME Elite IV Contractors PHONE# EXT' <br /> 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> (209 } 461-6342 <br /> CITY Stockton STATE (tea 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 and FEDERAL law��s.`, _ � <br /> APPLICANT'S SIGNATURE: ✓lam I��%/�C.C./L�X DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ 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 <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: I ) <br /> T <br /> COMMENTS: <br /> AD <br /> SA�JU� ?y zo <br /> y�CT1 PgRT AI <br /> TqL <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ <br /> ASSIGNED TO: , EMPLOYEE#: DATE: :i _ <br /> Date Service Completed (if alt y completed): SERVICE CODE: g PIE: <br /> 3 <br /> Fee Amount: Amount Palc�L�� Payment Date 72t� <br /> Payment Type Invoice# Ch k# ,*81032e'7 Rec ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />