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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST <br />BUSINESS NAME <br />Elite IV Contractors461-6337 <br />PHONE# Ext. <br />/# <br />EMPLOYEE#: �� <br />FAx# <br />( 209) 461-6342 <br />CITY Stockton <br />STATE Ca ZIP <br />95205 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />Rupi Padda <br />FACILRYNAME Waterloo Shell <br />SITE ADDRESS 4315E <br />Fee Amount: <br />Waterloo Rd <br />S OD <br />Stockton <br />95205 <br />Street Number <br />Direc <br />Street Name <br />Check # -7.4;I f p3�s s <br />City <br />Zio Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />(209) 914-8735 <br />aS-7 )W <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />hi)C <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />Megan Mitchell <br />COMMENTS: <br />BUSINESS NAME <br />Elite IV Contractors461-6337 <br />PHONE# Ext. <br />HOME or MAILING ADDRESS 2535 Wigwam Dr <br />9 <br />EMPLOYEE#: �� <br />FAx# <br />( 209) 461-6342 <br />CITY Stockton <br />STATE Ca ZIP <br />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 />1 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: 7e44 giIL 72G - DATE:�b I I <br />PROPERTY / BUSINESS OWNER❑OPERAT4 /MANAGER ❑ OTHER AUTHORIZED AGENT I 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, 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 environmental1site 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 />Drovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: OGI <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE#: �� <br />DATE: a_ -7-1 <br />ASSIGNED TO: _ <br />EMPLOYEE #: <br />DATE: — (71 <br />Date Service Compie a (i already completed): <br />SERVICE CODE: <br />P I E: 3 <br />Fee Amount: <br />Amount Paid <br />S OD <br />Payment Date <br />7 <br />Payment Type vl <br />Invoice # <br />Check # -7.4;I f p3�s s <br />Received y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />