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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> qsT "D � . SWner ;� <br /> OWNER / OPERATOR <br /> Vikash CHECK If BILLING ADDRESS <br /> FACILITY NAME Save on Fuel <br /> SITE ADDRESS 420 W Yosemite Ave Manteca X5336 4753 7 <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 /> ( 209 ) 239-4700 ;?/ I y <br /> PHONE #2 ExT. BOS DISTRICT LOCATtCpDE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 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 ) 4614342 <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 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 ❑ OPERATOR / AANAGER ❑ OTHER AUTHORIZED AGENT rJ 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the same time it� l ided to me or <br /> my representative. �Q °4�yi��Cg <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> SAIV 2®19 <br /> CO <br /> RT/PjFNT <br /> ACCEPTED BY: ✓ EMPLOYEE #: / i DATE: �7 <br /> ASSIGNED TO : ` EMPLOYEE #: DATE: <br /> /'✓C-v! <br /> Date Service Completed (ifaireadycompleted) : SERVICECODE : � PIE �� <br /> Fee Amount:` Amount Paid Lz�l Payment Date 1/1 � f <br /> Payment Type Invoice # Check # qzl 67 cLReceived By : l <br /> 1 <br /> i <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />