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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> IJ ST FAA00 100 IS ( M02 <br /> � <br /> OWNER / OPERATOR <br /> Chako Thomas CHECK if BILLING ADDRESS <br /> FACILITY NAME Emils Liquor <br /> SITE ADDRESS 1405 California St Escalon 95320 <br /> Street Number Direction I E 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 Exr. APN # LAND USE APPLICATION # <br /> ( 209 ) 499-2693 <br /> PHONE #2 Exrj BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE RE' QUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS © <br /> BUSINESS NAME PHONE # Exr, <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: 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 : v ' I <br /> PROPERTY / BUSINESS OWNER 13OPERATO MANAGER ❑ OTHER AUTHORIZED AGENT EI Office Assistant <br /> If APPLICANT Is not the BILLING PARTY. proof of authorization to sign t5 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 is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : S YJ <br /> �ry <br /> COMMENTS: it <br /> y N�� QU, 6 2Q�9 <br /> �4TyOF IFN UN <br /> ACCEPTED BY: EMPLOYEE #: / DATE: *�W T <br /> ASSIGNED TO : � _ � EMPLOYEE M o03 DATE; ' � / :� <br /> Date Service Completed (if already completed : SERVICE CODE : / P 1 E <br /> Fee Amount: � `� Amount Paid Payment Date 7 � G <br /> Payment Type s� Invoice # Check # � ss 8 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />