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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property j T 'e,T�% FACILITY ID # SERVICE REQUEST # PHONE# 209 s fI �/!2'� Lk� fo Resale FAX # ( 209) 461-6342 CITY Stockton OWNER I OPERATOR CHECK if BILLING ADDRESS D Pete Date Service Com eted (if already completed): FACILITY NAME Quick Shop Fee Amount: 4 SITE ADDRESS 2072 W I Yosemite Ave Payment Type Manteca 95337 Street Number ctlon Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE iZ'P PHONE #1 EXT• APN # LAND USE APPLICATION # ( 209) 345-1689 PHONE R EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Megan Mitchell j T 'e,T�% CHECK If BILLING ADDRESS 13 BUSINESS NAMEElite IV Contractors PHONE# 209 EXT• 461-6337 HOME or MAILING ADDRESS 2535 Wigwam Dr EMPLOYEE #: FAX # ( 209) 461-6342 CITY Stockton STATE Ca z'P 95205 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: Megan Mtchea DATE: 7/10/2017 PROPERTY/ BtIS1NESS OWNERQ OPERATOR MANAGER El OTHER AUTHORIZED L AGENT d. Office Assistant If APPLICANT is not the BILGING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. IIIAJ—Ay&9:a -_ TYPE OF SERVICE REQUESTED:• j T 'e,T�% ` �� •`tY I COMMENTS: SqNJUL 1 2017 � FNVRo ��UN NF -Ar THo r'gpN7A �7Y ACCEPTED BY: EMPLOYEE #: DATE: ll o 1101 ASSIGNED TO:�AOa V0 EMPLOYEE M DATE: —7 Date Service Com eted (if already completed): `` SERVICE CODE: 1 PIE: Fee Amount: 4 Amount Paid Payment Type Invoice # 2 9 tf t f7 Check # �' D , 1 � � . Received Bye EHD 48-02-025 0 2 -- REVISED 11/17/2003 U [_ 10 fflfpRM (Golden Rod) ENVIRONNIIENTL Hr.-AI-TH