Laserfiche WebLink
SAN JOAQUIN COUNTY K NVIRJONMENTAL. HEALTH DEPARTMENT <br /> SERV IGH <br /> REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST It <br /> A 0OD ) so� <br /> OWNER / OPERATOR Jeet CHECK if BILLING ADDRESSD <br /> FACILITY NAME Manteca Liquor Food and Gas <br /> SITE ADDRESS 890 N Main St Manteca 95336 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number E Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 209 ) 765-2619 ZZ ?Uzo 0 <br /> PHONE #2 E)c • BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE RE' QUESTOR <br /> REQUESTOR Megan Mitchell CHEcl< if BILLING ADDRESS ® <br /> PHONE # EXT. <br /> BUSINESS NAME Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESSFAX # <br /> 2535 Wigwam Dr ( 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 /> 1 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 : 29w�! DATE : 4/21 /2020 <br /> PROPERTY I BUSINESS OWNER 13OPERATOR / MANAGER 0 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 /> f0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the Same time It is provided t0 me or <br /> my representative . 14% Ah <br /> YAJ <br /> TYPE OF SERVICE REQUESTED : <br /> COtdtAENTS : <br /> ApR ? ? <br /> Sq 20 a <br /> N <br /> °AQUJv <br /> NEACTh10 MECO TY <br /> ACCEPTED BY : VA <br /> EMPLOYEE M DATE: _ Z �' yF ) <br /> ;t 1 <br /> ASSIGNED TO : Y � I� t r� EMPLOYEE M DATE: I ' ' & 10 <br /> Date Service Completed ( If already completed : SERVICE CODE: ; ? PIE: :307 <br /> Fee Amount : , c ' �� 1 Amount Pai �Y/ , DD Payment Date <br /> Payment Type / invoice # Check # 1 $O Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod) <br /> 07/17/08 <br />