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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA vHS�-61 I,0 0-191363 <br /> OWNER/OPERATOR <br /> G urbeet Singh CHECK If BILLING ADDRESS E] <br /> FACILITY NAME DK Investments <br /> SITE ADDRESS 9484 West Lane Stockton -7 95210 <br /> Street Number I Direction me 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 USE APPLICATION# <br /> (925 ) 960-3797 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If13ILLINGADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 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 /> 1 also certify that 1 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: W2 jGl yli W'e& //� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Office Assistant <br /> IfAPPLICA.NT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or fe�H+v mental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avaitalSlA Arl il�6�n�.tirue it is <br /> provided to me or my representative. ~�V 1 HE�`E. <br /> TYPE OF SERVICE REQUESTED: <br /> t <br /> till <br /> COMMENTS: 2018 <br /> SAN JOAOUIIV CODON <br /> ENVIRONME <br /> HEALTH pEPARTMENT <br /> L <br /> ACCEPTED BY: EMPLOYEE M DATE: , - 3 — <br /> ASSIGNED TO: W.1 EMPLOYEE M DATE: -,-q - 3-- <br /> Date Service Completed (if already completed): SERVICE CODE: 1 RJ P 1 E: <br /> Fee Amount: Amount Paid TS(p. �� Payment Date '3 <br /> Payment TypeInvoice# Che k# 03 eceived By: <br /> EHD 48-02-025 , <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />