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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> as tT1a17 000 vel ey � Q ►�Z b <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Estes Express Lines <br /> SITE ADDRESS 7611S Airport Way Stockton 95206 <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 #'I EXT. # LAND USE APPLICATION # <br /> ( ) 209-982-1841 t APN 1 -i oC 2 <br /> PHONE #2 Exr. J BOS DISTRICT l LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # Exr• <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: 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 /> also certify that I have prepared this application and that the work be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE : - DATE : 7/3/2020 <br /> PROPERTY / BUSINESS OWNER ❑ 11LLINGPAR <br /> ATOR ANAGE OTHER AUTHORIZED AGENT ® Office Assistant <br /> If APPLICANT Is not thTY, 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the Same time It Irovided to me or <br /> my representative . �7c <br /> TYPE OF SERVICE REQUESTED : C C r <br /> COMMENTS: Alt � 9 ?4Z0 <br /> SAFN O �gQUIN C <br /> � <br /> HFgCTH �ARNTY <br /> WA/ Tr <br /> ACCEPTED BY: &ImaA <br /> /1/1 I }EMPLOYEE #: DATE: J , Z� <br /> ASSIGNED TO : , A \ `C EMPLOYEE #: DATE: / V�' <br /> Date Service Completed (if already completed) : SERVICE CODE : lJ P 1 E: ��301 <br /> Fee Amount: ` 1 V , Amount Pa (]v Payment Date 7 <br /> Payment Type { � a� Invoice # Check # f b �glS Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />