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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail <br /> OWNER / OPERATOR 1 <br /> Eugenie Valdez CHECK If BILLING ADDRESS <br /> FACILITY NAME J&L Market <br /> SITE ADDRESS ,M297 S EI Dorado St Stockton 95231 <br /> StrDea Number Direction I 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 ) 982-0897 0 <br /> PHONE #2 <br /> EXT. BOS DISTRICT LOCATION �. 1 (�U <br /> ( ) N 14 tR0 COU/y <br /> CONTRACTOR / SERVICE REQUESTOR FpgR M�N <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209 461 -6337 <br /> i <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, f <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 : <br /> Office Assistant <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT U <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 assessment i <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is j <br /> provided to me or my represent tive. <br /> TYPE OF SERVICE REQUESTED : oil <br /> t Can IvtS� c <br /> COMMENTS: <br /> JAN 22 2019 j <br /> IAL I' <br /> T14 r�, s- 10) Anr.RnF- <br /> I <br /> I <br /> ACCEPTED BY: EMPLOYEE #: ` ol DATE: _ ( / c, j <br /> ASSIGNED TO : V� n. l ` �Lo EMPLOYEE #: `w / DATE: <br /> Date Service Completed ( if already completed) : t o20 ( SERVICE CODE : / ( CT P / E: J( 04 <br /> Fee Amount: C 2Lt�I � �� Amount Paid -T04, Payment Payment Date <br /> Payment Type / � Invoice # Ch ek # 3c f 3 Rece ved By : <br /> / Y \ S�`lolll3 <br /> EHD 48-02-025 I1 �� 1 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 \\\, <br />