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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />A <br />_-31 il°i'-'lO 1 <br />OWNER I OPERATOR <br />BUSINESS NAME Elite IV Contractors <br />Rupi Padda <br />ExT. <br />CHECK if BILLING ADDRESSO <br />FACILITY NAME <br />209 <br />461-6337 <br />Waterloo Food Mart <br />tis Nt,°'qQ�I? <br />�4 h'ODbDUN <br />SITEADDRESS4315 <br />E <br />Waterloo Rd <br />( 209) <br />Stockton <br />9525 <br />Street Number <br />Direction <br />tenet Name <br />DATE: - <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />P i E: � �o <br />Street Number <br />Street Name <br />CITY <br />Payment Date <br />STATE ZIP <br />PHONE #1 EXT. <br />Invoice # <br />APN # <br />LAND USE APPLICATION # <br />Q09-9131-3674 <br />OS+ <br />PHONE#2 EXT. <br />BOS DISTRIC�j <br />LOCATIOOJNCODE <br />( ) <br />db- 1 <br />"1 1 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Megan Mitchell <br />COMMENTS: <br />CHECK If BILLING ADDRESS® <br />BUSINESS NAME Elite IV Contractors <br />PHONE# <br />ExT. <br />209 <br />461-6337 <br />HOME Or MAILING ADDRESS <br />tis Nt,°'qQ�I? <br />�4 h'ODbDUN <br />2535 Wigwam Dr <br />ACCEPTED BY: -7- <br />( 209) <br />461-6342 <br />CITY Stockton <br />STATE Ca <br />ZIP 95205 <br />BILLING ACKNOWLEDGEMENT: 1, 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: DATE: (, /// // 1 <br />PROPERTY/ BUSINESS OVVNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT® Office Assistant <br />If APPLICANT is not the BILLING PAR7T 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 the same time it is <br />provided to me or my representative. <br />s <br />TYPE OF SERVICE REQUESTED:OST <br />Y <br />COMMENTS: <br />:,�pvI <br />X018 <br />tis Nt,°'qQ�I? <br />�4 h'ODbDUN <br />ACCEPTED BY: -7- <br />EMPLOYEE #: W I <br />DATE: T <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: - <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />$ <br />P i E: � �o <br />Fee Amount: <br />Amount Paid <br />4* Gjr ". <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: ( JA-. <br />EHD 48-02-025 d�1� <br />REVISED 11/17/2003 <br />`��' 44-1--71i�o093YO <br />S�l ig <br />R FORM ( olden Rod) <br />VDpe-rp <br />