Laserfiche WebLink
• 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE# ExT <br />9) 461-6337 <br />HOME or MAILING ADDRESS <br />2535 Wigwam Dr <br />L 7 <br />h <br />OWNER / OPERATOR <br />Bob Lutz <br />CHECK HBILLING ADORESS <br />FACILITY NAME EI Dorado Shell <br />SITEADDRESS 2320 <br />EI Dorado St <br />Stockton <br />F79:5:204 <br />Street Number <br />Direction t t <br />EMPLOYEE #: <br />C' <br />ode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SERVICE CODE: <br />P l E: - G" <br />Street Number <br />Pai <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Err. <br />APN # <br />LAND USE APPLICATION # <br />1209► 943-1311 <br />103c) <br />PHONE#2 ExT• <br />BOS DISTRICT <br />LOCATION <br />( 1Co <br />L <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />13 <br />Megan Mitchell CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Elite IV Contractors <br />PHONE# ExT <br />9) 461-6337 <br />HOME or MAILING ADDRESS <br />2535 Wigwam Dr <br />FAX # <br />( ) 461-6342 <br />CITY Stockton STATE Ca ZIP <br />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: Y&g. �/2r DATE: 2/19/20/18 <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR/MANAGER [3� <br />OTHER AUTHORIZED AGENT I�_Ue!'Assistant <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 isAA ftg .at the same time it is <br />provided to me or my representative.still <br />i /y� alt!►/T <br />TYPE OF SERVICE REQUESTED.�� <br />pop <br />COMMENTS: <br />10 2018 <br />oRONME OU 1VTY <br />HeqT M OEPAR 1WENT <br />ACCEPTED BY: 21 r <br />EMPLOYEE #: <br />DATE:�% <br />L I <br />ASSIGNED TO: L� <br />EMPLOYEE #: <br />DATE: _ / <br />� .- <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />P l E: - G" <br />Fee Amount:Amount <br />Pai <br />Llt—1 Ott <br />Payment Date �D <br />Payment Type <br />Invoice # <br />Z <br />Ri d By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />