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Osf' N 6.0 t; AW11_! IN Ky0LJNTY f`±-,E NVIRONMENTAL G° 1EAI.14`I f , L� Lk ' A� k21' IUikvNT <br /> S) E=: F VICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Detail Fuel FIVE 0 `J SRm © $ g 51 <br /> OWNER IOPERATOR -- —=G- -= <br /> Lawrence Wight CHECK if BILLING ADDRESS <br /> FACILITY NAME Wight Holdings <br /> SITEADDRESs2908 W Benjamin Holt Dr Stockton 95207 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address ) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #'I EXT. APN # LAND USE APPLICATION # <br /> ( 209 478 - 5552 <br /> T02993-7825 Cell EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK ifBILLINGADDRESS �i�t <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT, <br /> (? 09 )461 - 6337 _ <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx # <br /> ( 209 461 -6342 <br /> CITY Stockton STATCA 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 /> I 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 laws , <br /> APPLICANT' S SIGNATURE : CaIL � N � DATE : IS 2 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Manager <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 assessme gf�mmation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it is prop 1FF'' �arr <br /> my representative. CIA / I <br /> TYPE OF SERVICE REQUESTED ; tn <br /> t D <br /> COMMENTS : <br /> ?D y <br /> HE ROHM CO 1'Y <br /> TH DEPARTM <br /> 1 . <br /> NT <br /> ACCEPTED BY: EMPLOYEE # : DATE : 4 <br /> ASSIGNED TO : Pe <br /> 111 . EMPLOYEE #: DATE: ' � Z <br /> Date Service Completed ( if already completed ) , SERVICECODE : � �2� PIE: Z � 0� <br /> Fee Amount : Amount Paid Payment Date 3 2l Z <br /> Payment Type Vi Invoice # Check # Received By; <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />