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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />BUSINESS NAM <br />lite IV Contractors <br />FACILITY ID # <br />PHONE# <br />209 <br />SERVICE <br />REQUEST # <br />Gas &Food Retail <br />FAX# <br />04 <br />��--GV ;3 <br />( 209) <br />moP 30A <br />65LIOL� <br />OWNER I OPERATOR <br />ZIP 95742 <br />CHECK If BILLING ADDRESS <br />Thien Phan <br />ACCEPTED BY: Ft <br />FACILITY NAME California Stop <br />DATE: ' <br />SITE ADDRESS 2224 <br />L I <br />Manthey <br />Road <br />EMPLOYEE #: <br />DATE: 3 <br />Stockton <br />already completed): <br />75 Pot <br />Street Number <br />Direction <br />Fee Amount: <br />Street Name <br />�d Payment Date 3 30 2l <br />Payment Type ;� <br />cityZ <br />Check # ZZ%b D Recei ed By. <br />Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Same as above <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE <br />APPLICATION # <br />( 209 1 406-1484 <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT "71LOCATION <br />CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />Deborah Jones <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized <br />CHECK If BILLING ADDRESS <br />BUSINESS NAM <br />lite IV Contractors <br />PHONE# <br />209 <br />ExT. <br />461-6337 <br />HOME or MAILING ADDRESS <br />V <br />FAX# <br />2535 Wigwam Drive <br />( 209) <br />461-6342 <br />CITY Stockton <br />CA STATE <br />ZIP 95742 <br />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 busmi ess 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, .Ytandards, STATE and FEDERAL laws. <br />APPLICANT'S <br />Annnrri01 <br />v / RiicTnrrcc nl\'NRR ❑ OPIsIL11'OR AGER ❑ O7'IIEK AUTHORIZED AGENT ®(�j►'%) �/y),���/,�Q ,1�(,QQ,{,((�Q//)� <br />If APPLICANT is not IheBILLIVG PARTI: proof of authorizatiolr to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: V✓lleu 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />nrovided to me or my representative. kc <br />TYPE OF SERVICE REQUESTED:,ITD i LPA <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />COMMENTS: <br />V <br />V <br />841V'10 0 `%2% <br />yEq <br />THO Ng /V T4 <br />ACCEPTED BY: Ft <br />EMPLOYEE #: <br />DATE: ' <br />ASSIGNED TO: V,a <br />� ��� <br />EMPLOYEE #: <br />DATE: 3 <br />Date Service Complete (if <br />already completed): <br />SERVICE CODE: <br />P 1 E; b% <br />Fee Amount: <br />60 Amount P�, <br />�d Payment Date 3 30 2l <br />Payment Type ;� <br />Invoice # <br />Check # ZZ%b D Recei ed By. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />