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W <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station <br />PHONE # EXT. <br />Elite IV Contractors <br />OWNER I OPERATOR <br />209 <br />HOME Or MAILING ADDRESS <br />CHECK If BILLING ADDRESS <br />Swaran Chouchan <br />2535 Wigwam Dr <br />FACILITY NAME <br />t 209 1 <br />Super Center Mart <br />STATE Ca ZIP 95205 <br />SITE ADDRESS <br />E <br />Amount Paid <br />Payment Date <br />Payment Type <br />95206 <br />701 Street Number <br />Direction <br />Charter Way <br />Street Name <br />Stockton Cit <br />C de <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONt #1 EXT. <br />APN #r <br />LAND USE APPLICATION# <br />( 209 ) 467-0305 <br />PIIONE #2 EXT. <br />BOS DISTRICT —7 <br />FGCATIQ�COIIE <br />( 209) 993-1298 <br />__11 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Carrie Miller <br />CHECK If 1311_LING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />Elite IV Contractors <br />EMPLOYEE #: <br />209 <br />HOME Or MAILING ADDRESS <br />FAX# <br />2535 Wigwam Dr <br />Date Service Completed (if <br />t 209 1 <br />CITY Stockton <br />STATE Ca ZIP 95205 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sante, <br />acknowledge that all site and/or project specific ENVIRONMEMI'Al. HGALThi DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this forni. <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 JOAQLVN <br />COUNTY Ordinance C odes. Standards, STATE and FEDERAL laws. <br />APPLICANT'S S1C;NATUr—R�'� 70k&,&E: 70k&,&DATE: 6/22/16 <br />PROPERTY / BusmmS OWNERO OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT IR Office Manager <br />If APPLICANT is not the BILLING 11.I RTY, proof of authorization to sigh is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED; <br />Repair or replace failed annular sensor <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if <br />already completed): <br />SERVICE CODE: <br />PI E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />I I <br />Check # <br />Received By: <br />fn 1 <br />EHD 48-02-025 SR ( SR FORM (Golden Rod) <br />REVISED 11/17/2003 I' <br />