Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT' <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />Gas & Food Retail <br />ExT. <br />Elite IV Contractors <br />209 <br />461-6337 <br />OWNER / OPERATOR <br />FAX # <br />Atwal Inc / Plaza Liquors <br />( 209) <br />CHECK If BILLING ADDRESS <br />FACILITYNAME Plaza Liquors <br />STATE CA <br />zip 95205 <br />SITE ADDRESS $00 <br />S <br />Cherokee Lane <br />EMPLOYEE #: <br />Lodi <br />95240 <br />Street Number <br />Direction <br />t eatan <br />DATE: �Z� <br />city <br />21 ode <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Date Service Completed'�(alreadycompl ed): <br />SERVICE CODE: <br />Street Number <br />Street Name <br />CITY <br />Amount Paid <br />STATE <br />ZIP <br />PHONE #1 ExT• <br />Payment Type �Y <br />APN # <br />LAND USE APPLICATION # <br />(209) 368-0127 <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />Deborah Jones <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# <br />ExT. <br />Elite IV Contractors <br />209 <br />461-6337 <br />HOME or MAILING ADDRESS <br />FAX # <br />2535 Wigwam Drive <br />( 209) <br />461-6342 <br />CITY Stockton <br />STATE CA <br />zip 95205 <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 lj�wS. <br />APPLICANT'S SIGN <br />DACE: <br />5/21/2021 <br />I'IiOPEIiTY/BUSINESS OWNF.a❑ OPERATOR/ ANACER❑ O'r1iERAUTHOa1LEnAGEN'r® AdminlStratlVeASSIStant <br />1,%APPLICAN7is not the BILLING PARTY, proof of art1110rization to sign is required TiNe <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 <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'T'H DEPARTMENT as soon as it is available and at the s�Prt ale It iS <br />provided to me or my representative. f� <br />�� No <br />TYPE OF SERVICE REQUESTED: T f "J� <br />COMMENTS: sq N <br />N�A�r 20 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />i� <br />pry <br />✓r <br />JD�PT <br />4NoUF <br />RTNjE <br />ACCEPTED BY: <br />1W R=LV <br />EMPLOYEE #: <br />DATE:771 <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: �Z� <br />Date Service Completed'�(alreadycompl ed): <br />SERVICE CODE: <br />PIE:, <br />Fee Amount: a <br />Amount Paid <br />T�' UD <br />Payment Date <br />Payment Type �Y <br />Invoice # <br />Check # 8 <br />Receive By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />i� <br />pry <br />✓r <br />