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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID if <br />61 WV 1 bR <br />SERVICE REQUEST if , , , , <br />t i : A, 1 <br />OWNER! OPERATOR <br />Jawinder Singh CHECK If BILLING ADDRESS <br />FACILITY NAME JD Service Station <br />SITE ADDRESS 9015 <br />Street Number <br />W <br />Direction <br />Walnut Grove Rd <br />Street Name <br />Thornton <br />City <br />95686 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( 209 ) 794-8993 <br />APN # <br />0 t t ; ,t ,t \ , <br />LAND USE APPLICATION # <br />PHONE #2 Ext. SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR iv <br />Megan M CHECK If BILLING ADDRESS <br />BUSINESS NAME Elite IV Contractors PHONE # <br />( 209-461-6337 <br />FAX # <br />(209) 461-6342 <br />EXT. <br />HOME or MAILING ADDRESS 2535 Wigwam Dr <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 <br />or 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: <br />PROPERTY! BUSINESS OwNERD OPERATOR VMANACER 0 <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 <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 plAure it is <br />rovided to me or m representative. <br />TYPE OF SERVICE REQUESTED: r T 1)-6-yok;(7 <br />COMMENTS: <br />"cuEivED <br />MAY 30 2018 <br />SAN dr, , .wAQUIAI , tNVI NM &Y ‘"ENUUNTy HEALTH D ep TAL <br />ARTm ENT <br />ACCEPTED BY: ..-L wtctvicw.... EMPLOYEE #: q (00 / DATE: c. 'O ..../ <br />A <br />ASSIGNED TO: . 'I/an . 1 <br />EMPLOYEE #: C/CC)/ DATE: 4. .30 1 Z <br />Date Service Completed (If already cot-Deleted): SERVICE CODE: l C.7 g P/E: . 50s <br />Fee Amount: La Amount Paid z/6-6. DD Payment Date (573O / g <br />Payment Type Invoice # Ch/6 #a„,_?7,4.3 01-- Receive By: (0 <br />, // DATE: <br />OTHER AUTHORIZED AGENT VI <br />Amie <br />Office Assistant <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003