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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 oo v3n <br /> OWNER / OPERATOR <br /> Rupi Padda CHECK If BILLING ADDRESS <br /> FACILITY NAME Waterloo Shell <br /> SITE ADDRESS 4315 E Waterloo Rd Stockton 95215 <br /> Street Number Directlon Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #t Exr. APN # LAND USE APPLICATION # <br /> ( 209 ) 931 -3674 -7�] <br /> PHONE #2 ExT• BOS DISTRICT- <br /> LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # Ems' <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr <br /> (209-4¢ 1 -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 /> 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 : p DATE : � J '�`- <br /> PROPERTY / BUSINESS OWNER ❑ OPERAT R I MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Assistant <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 �rmation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provl " dq it <br /> my representative . u �SJ <br /> TYPE OF SERVICE REQUESTED : <br /> l <br /> COMMENTS: S,qVF <br /> � ,s <br /> �Y T�RO�fH C0iv <br /> MF�y� <br /> ACCEPTED BY : ^ EMPLOYEE # : DATE ; � 2 i <br /> ASSIGNED TO : EMPLOYEE M l DATE , <br /> Date Service Competed ( if already completed) : SERVICE CODE ; !kx 1 . 1 PIE : <br /> Fee Amount : Amount PAW% Payment Date <br /> Payment Typ V Invoice # Check # Flo2L946; Receiv d By: <br /> EHD 48-02-025 eve� Q` SR FORM (Golden Rod) <br /> 07/17/08 "l " / ' <br />