Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR )i /� /I /n CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME US e irl Oe )e l vf'/ ? Illty <br /> SITEADDRESS 2072 W Yosemite Ave Manteca 95337 <br /> Street Number Direction I Street Name City z1v Code <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 /> ( 209 ) 345-1689 2 �, 2 � LODl <br /> PHONE #2 EXT• BOS DISTRICT <br /> IF loucO <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell 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 /> 9 ( 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 /> 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 : w7�r� DATE : 9/24/2019 <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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it IS provided t0 re Or <br /> my representative. �V <br /> Wir <br /> TYPE OF SERVICE REQUESTED : S� t** . 1A �� <br /> COMMENTS: <br /> J, 2019 <br /> H pFpq y At 4 <br /> `ANT <br /> ACCEPTED BY: EMPLOYEE #: / DATE: / <br /> ASSIGNED TO : S /f /J �•- EMPLOYEE #: Mo <br /> DATE: ley <br /> Date Service Completed ( if already comp d) . SERVICE CODE : / GI PIE# <br /> Fee Amount: `� Amount Pai � Q-D Payment Date Ab � <br /> Payment Type S� Invoice # Check # 9GG X22 Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />