Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Bcet*t— Gas S�-f ibn � d 2 �f a fb 4lf <br /> OWNER / OPERATOR <br /> Richard Sarris CHECK if BILLING ADDRESS <br /> FACILITYNAME Adelfos Inc. - Arco # 83849 <br /> SITE ADDRESS 3443 Stockton 95205 <br /> 2750 Cherokee Rd <br /> Street Number DirectionStreet Name City Zip Code <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) <br /> SAME Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209) 601 -7292 <br /> ATION CODE <br /> PHONE #2 EXT. BOS DISTRICT LOC <br /> ( 209) 570-8976 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # ExT. <br /> 2094 461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam or FAX # <br /> ( 209 ) 461 -6340 <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 /> i <br /> 1 also certify that I have prepared this Of cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards TATE and FEDERAL lawA /k <br /> 1 / 12/2022 <br /> APPLICANT'S SIGNATURE : DATE : <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 0 Office Manager <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 provided to me or <br /> my representative . PA 1.4PRA <br /> ' <br /> TYPE OF SERVICE REQUESTED: S ` ' Y <br /> Q <br /> COMMENTS: /� � JqN <br /> (� <br /> s <br /> N q NO� u/N CO ?? <br /> HCFPgR� NTY <br /> ACCEPTED BY: � LI txa�J EMPLOYEE #: DATE : <br /> ASSIGNED TO : �>� n >� Of7 d� EMPLOYEE # : DATE: I � 3 22- <br /> Date Service Completed (if already completed) : — SERVICE CODE: qo �qqF PIE : 2W9 <br /> Fee Amount: tom— Amount Pai tIC"6 , b� Payment Date ,1Z <br /> Payment Type V l ` Invoice # Check # 135 37 Received By: <br /> 137311 13 � <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />