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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> In WO <br /> OWNER/OPERATOR <br /> Andrew CHECK if BILLING ADDRESS <br /> FACILITY NAME River Point Marina <br /> SITE ADDRESS 4950 Buckly ove 95219 <br /> Stockton <br /> Street Number Direction 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 LAND USE APPLICATION# <br /> ( 209 ) 649-8171 p��� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION MODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORg <br /> Me an M CHECK if BILLING ADDRESSE] <br /> BUSINESS DAME Elite IV Contractors PHONE# ExT. <br /> 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> (209 ) 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: DATE: 9/17/2018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANACER ❑ OTHER AUTHORIZED AGENT n 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, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geote .caall data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 4g111iCJ,i� available and at the same time it is <br /> provided to me or my representative. 0E - Ap, r ,� I <br /> TYPE OF SERVICE REQUESTED: ft <br /> k� <br /> COMMENTS; SAN 47 201 SEP 17 2018 <br /> 4OA14Eq�RpNME OU <br /> H p NTAt ENVIRO,►NE <br /> EpgRrMENNTA <br /> t HFA!TH OERgR7- 4E <br /> ACCEPTED BY: n �� EMPLOYEE#: CA DATE: -n <br /> ASSIGNED TO: W _ EMPLOYEE#: Cl� DATE: Ct -fn 1` <br /> Date Service Completed (if already completed): SERVICE CODE: LLi'$ PIE: <br /> Fee Amount: 6 Amount PaiZIrTSS �v Payment Date <br /> Payment Type 'sr-- Invoice# Ch k# 11 <br /> Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />