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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> fA OW 758 67 S � W85 HS2 <br /> OWNER / OPERATOR <br /> Keith Sample CHECK If BILLING ADDRESS <br /> FACILITY NAME UNFI <br /> SITE ADDRESS 1990 Piccoli Road Stockton 95215 <br /> Street Number Direction Street Name <br /> City Zi 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 /> ( 209 ) 931 -7431 Office <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 327 -2053 Cell <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLINGADDRESS13 <br /> BUSINESS NAME Elite IV Contractors PHONE # ExT. <br /> ( 2091 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 , <br /> APPLICANT' S SIGNATURE : DATE : 7/ 1 /22 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 13 Office Manager <br /> /f 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 isv ded to me or <br /> my representative , r <br /> 1 V1 <br /> TYPE OF SERVICE REQUESTED : � ) p <br /> COMMENTS : �T D <br /> SAN JJul <br /> AlC �T <br /> o C� <br /> �V� Y <br /> HEALTH <br /> A <br /> ACCEPTED BY: —� G h� EMPLOYEE #: DATE : �711 <br /> ASSIGNED TO : L r EMPLOYEE M DATE : '7 Z2� <br /> Date Service Completed ( if already completed) : SERVICE CODE: ' ` / PIE;;;r <br /> Fee Amount: Amount Pald,1? 4LI </ �� Payment Date ? r ZZ <br /> Payment Type Gam— Invoice # Check # is �' 1 Z Received By: - <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 �f <br /> I <br />