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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> rA OX i3q 3 <br /> OWNER / OPERATOR <br /> Jeet Sandhu CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> Manteca Liquor & Food <br /> SITE ADDRESS 890 N Main St. 95336 <br /> Manteca <br /> Street NumberDirection I Street Name City ZID 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) 239 -4550 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( 209 ) 7654550 Cell <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # ExT. <br /> P09-461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx # <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 : La 7221 DATE : 2/6/2024 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 0 Office Manager <br /> If APPLICANT IS not the BILLING PARTY, proof of authorization t0 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 result$ , 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 . <br /> TYPE OF SERVICE REQUESTED : (/C J T kt 3 M <br /> COMMENTS : n 0o ilk <br /> - ik-e �D / V JD <br /> SA A/ FEB <br /> N�ACTNORpMEN TY <br /> q C <br /> ACCEPTED BY: �ta J EMPLOYEE #: DATE: 2 Z � T <br /> ASSIGNED TO : EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �2� PIE: 1000 <br /> Fee Amount : 2 � Amount Paid f '? . db Payment Date 1A .2 <br /> Payment Type V/` 54�. Invoice # Check # I (� ' 3 SS� Receive By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />