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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> f <br /> Lr) ��Z 0 � <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAMEOWN <br /> SITE ADDRESS � �' 1 ( ''AA ,, r'�� m Tol � � <br /> �� Street Dir/cion rV� Street Name Cit ZI Code <br /> Number <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 925 ) 783-6102 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Megan Mitchell <br /> PHONE # Exr' <br /> BUSINESS NAME Elite IV Contractors ( 20961 -6337 <br /> FAx HOME or MAILING ADDRESS 2535 Wigwam Dr ( 209 ) 461 -6342 <br /> STATE Ca ZIP 95205 <br /> CITY Stockton <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. <br /> APPLICANT' S SIGNATURE : /"�i DATE : �U 1 <br /> PROPERTY i BUSINESS OWNER [3OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 13 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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it is pro ed to me or <br /> my representative . WWI <br /> f�^I <br /> TYPE OF SERVICE REQUESTED : (,lS <br /> JUjy <br /> COMMENTS: SgNL/O <br /> H 'NVi1i Uiy CO <br /> pAUN <br /> �UNPy <br /> HT <br /> ACCEPTED BY : % V �� EMPLOYEE #: �1 2� DATE: IP / / / 7 <br /> ASSIGNED TO : <br /> Wo toa re EMPLOYEE #: DATE: <br /> Date Service Completed (if already comp SERVICE CODE : �GJ� Z/ 1 FeeAmount: y�. 5Amount Pai , Payment Date lv /I <br /> Payment Type � � Invoice # Check # 0 �s Rece ved By : <br /> SR FORM (Golden Rod ) <br /> EHD 48-02-025 <br /> 07/17/08 <br />