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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Kul Sharma CHECK If BILLING ADDRESS <br /> FACILITY NAME Yosemite Avenue Arco Ampm <br /> SITE ADDRESS 1711 1 E Yosemite Ave Manteca 95336 <br /> Street Number Direction I Street Name Citv 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. APN# LAND USE APPLICATION# <br /> (51o ) 468-2371 .2. D9 1 C:> <br /> PHONE#Z EXT. BOS DISTRICT LOCATION C DE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan M CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# ExT• <br /> (209 ) 461-63371 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx# <br /> ( 209) 461-6342 <br /> CITY Stockton STATE Ca 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: ?/'r2Q %�2 DATE: (nom l <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[N 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 <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; S `�r <br /> COMMENTS: ' ' <br /> c-014'r, <br /> ACCEPTED BY: (� ����j�, EMPLOYEE#: ?,ii�7 O DATE; rJ 9 <br /> ASSIGNED TO: IL EMPLOYEE M D(� DATE: `f <br /> Date Service Completed (If Already completed): Ei SERVICE CODE: J 9 PIE: <br /> Fee Amount: (� 5� .�- Amount Paid r�s(o ,� Payment Date -1 C� <br /> Payment Type V t Invoice# Check# 3`ci�ZZJ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />