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l <br /> I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> �� lq� a <br /> OWNER / OPERATOR <br /> Sukhwinder Singh CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME Shell <br /> i <br /> I <br /> SITE ADDRESS 620 W Charter 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 #1 EXT, APN # LAND USE APPLICATION # <br /> (650 ) 740- 1718 <br /> PHONE #T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME 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: 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 /> 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 : <br /> PROPERTY / BUSINESS OWNER ❑ OPERAT R / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Office Assistant <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tilte <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 assment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time ItpS/�•�VQI=t2 Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : Se t D <br /> COMMENTS : y <br /> 20 <br /> 1JSNdOA� HQU1N COVHEALTpNM ��AN <br /> T <br /> ACCEPTED BY: 1 V� EMPLOYEE #: J DATE; <br /> ASSIGNED TO : t / ` ' � EMPLOYEE #: e7 DATE: 4;V1 <br /> e7 <br /> Date Service Completed (if already comple ed) : SERVICE CODE : P 1 E ; ` /J � <br /> Fee Amount ; `oe. Amount Paid Payment Date 1 14t <br /> Payment TypeViT Invoice # Check # <:? ������� Received By ./"/ <br /> �- <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />