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>r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERot <br /> VICEtR 114 !T# <br /> Retail 11'UU r S <br /> v� <br /> OWNER I OPERATOR <br /> Sim Grewal CHECK if BILLING ADDRESS <br /> FAGILrry NAME Country Markel Place <br /> SITEADDRESS 1789 W Charter Way Stockton 95206 <br /> beet Number I DiractionStreet Name citv Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Strait Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 941-2222 <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR 1 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 /> 1209 ) 461342 <br /> CITY Stockton STATE Ca ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <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 /> PRQPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTTIER AUTRORizED AGENT® Of ceAssiStant <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required 741le <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 enygi ntal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENv1RONMENTAL HEALTH DEPARTMENT as soon as it is aYAIIItWl t the same time it is <br /> provided to me or my representative. ������`` vv <br /> TYPE OF SERVICE REQUESTED, UA KAM <br /> \� <br /> COMMENTS: 0��1 <br /> SOP <br /> N <br /> ACCEPTED BY: <P <br /> EMPLOYEE#: 5 DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid `l�r r�� Payment Date <br /> Payment Type Invoice# Check# Rec Eve By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 712 003 <br />