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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID 1/ SERVICE REQUEST /E <br /> Retail FUeI oobl � � g su4 o ® azo <br /> OWNER / OPERATOR <br /> Ashish Boveja CHECKifBILLING ADDRESS <br /> FACILITY NAME My Mini Mart <br /> SITE ADDRESS 1 756 N Wilson Way Stockton 95205 <br /> Street Number Direction Streot Name Cit ZI Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Numbor Street Name <br /> CITY STATE ZIP <br /> PRONE #1 EXT, APN # LAND USE APPLICATION # <br /> (408 ) 204 - 1636 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT , <br /> Elite IV Contractors ( 209 -) 461l-6337 <br /> HOME Or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209 ) 461 -6342 <br /> CITY Stockton STATECA 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 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 : C � 7) e DATE : 5/24/24 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT m Office Manger <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time it provided to me or <br /> my representative , 1_ <br /> TYPE OF SERVICE REQUESTED : US fil EC <br /> COMMENTS : - 04111110F` <br /> JUN 0 <br /> 2024 <br /> SAN JOAQUIN CO <br /> HEALTH DC ARTTAN TY <br /> ENT <br /> ACCEPTED BY : EMPLOYEE # : DATE , Z� <br /> ASSIGNED TO : a. EMPLOYEE # : DATE: 2T <br /> Date Service Completed ( if already completed) : - - - SERVICECODE : t�� PI E : 23Q <br /> Fee Amount: Amount Pai ' Payment Date �p <br /> Payment Type � j Invoice # Check # I g / � � Rece ' ed By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/17/08 <br />