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• 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Resale �A WJ14'33- 1sJFQ017VT7 <br /> OWNER/OPERATOR <br /> Mandeep Gurm CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Hammer Lane Oil <br /> SITE ADDRESS 3304 W Hammer Lane Stockton 95219 <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#1 ExT. APN# LAND USE APPLICATION# <br /> (209) 992-1415 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT. <br /> Elite IV Contractors 205 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> ( ) 461-6342 <br /> CITY Stockton STATE Ca 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 laws. <br /> APPLICANT'S SIGNATURE: Mean f fjtcheU DATE: 7/5/2017 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTCX Office Assistant <br /> If APPLICANT is not the BILLLIVG 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: <br /> COMMENTS: <br /> f.p`(ku*rie,,A 0f &keek keak �t✓•kec*Dt- - vy- G rao fu r <br /> =V 01. \1JAVUatt S LD g-0 <br /> AUL 0 2017 <br /> ACCEPTED BY: FWV-1 00 EMPLOYEE#: DATE: NEgi�RaNM q�My <br /> ASSIGNED TO: FW[-'T2O EMPLOYEE M DATE: Fhr <br /> Date Service Completed (if already completed): SERVICE CODE: 03 P I E: �Q <br /> Fee Amount: G► Amount Pai �� �� Payment Date 7 & <br /> ` -� <br /> Payment Type /t)e-- Invoice# Ch k�#,�,1/J p / Received By: <br /> EHD 48-02-025 `�""� ` SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />