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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Harry Kamboj CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Harrys One Stop <br /> SITEADDRESS 1151 W Lousie Ave Manteca F95336 <br /> Street Number Direction StreetName Ci 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 /> 1 209 471-8047 '2-1(k Il I uok <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# ExT. <br /> Elite IV Contractors461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx# <br /> g (209) 461-6342 <br /> CIT" 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: W&IT <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT 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,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 environmental/site at <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sarML .A ��� <br /> provided to me or my representative. I!! <br /> TYPE OF SERVICE REQUESTED: SA.-O O <br /> COMMENTS: 1/OgQUt 18 <br /> H O M�Pot NAY <br /> ACCEPTED BY: EMPLOYEE#: Gtr I DATE: l <br /> ASSIGNED TO: Al "iEMPLOYEE M )0'�-) I <br /> DATE: 4_' <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: 08 <br /> Fee Amount: Amount Paid. Payment Date <br /> Payment Type ��� Invoice# C ck# *16- Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />