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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # S RACE REQUEST # <br /> A ► 5a <br /> S �Q � » � <br /> OWNER / OPERATOR <br /> Joe Dangtran CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Shell <br /> SITE ADDRESS 717 W 8th Street Stockton 95206 <br /> Street Number Direction Street Name Cit Zf 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 /> ( 408 ) 666-0009 <br /> PHONE #2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK if BILLING ADDRESS ® <br /> PHONE # EXT' <br /> BUSINESS NAME <br /> Elite IV Contractors 209 1 461 -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 , c7 <br /> APPLICANT' S SIGNATURE : DATE : <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 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 is pr vided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : user / t"el"Oe �4 <br /> COMMENTS: ,/U/V <br /> sAN k `� ® 2019 <br /> FN <br /> y�C y 01VP,gR��NiY <br /> ACCEPTED BY : <br /> ]tip EMPLOYEE DATE: <br /> " � MP � f <br /> ASSIGNED TO : n I c a EMPLOYEE #: ` DATE: <br /> Date Service Completed (if ahead om ed) : I v`-+ SERVICE CODE : P / E : 4:7 � <br /> Fee Amount : � >�2 �° Amount Paid r �� Payment Date (� do f <br /> Payment Type Invoice # Check M 9 ;L7. g L�.yy Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br /> I � <br />