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FUM <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REOUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK If BILLING ADDRESS® <br />SERVICE REQUEST # <br />�A � <br />BUSINESS NAMEPHONE <br />Elite IV Contractors <br />�� OWLII I <br />Gas Station <br />EXT. <br />461-6337 <br />HOME Or MAILING ADDRESS <br />2535 Wigwam Dr <br />OWNER / OPERATOR <br />461-6342 <br />CHECK If BILLING ADDRESS❑ <br />Dave Singh <br />zip 95205 <br />FAcILnrNAME Allstar Investments Inc <br />SITEADDRESS 3032 <br />Waterloo RdStockton <br />Ca <br />Street Number <br />DIr etion <br />Creel N e <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 />ExT, <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />(209) 321-1632 <br />PHONE #2 EXT. <br />SOS DISTRICT <br />LOCATION CODE <br />1-nNTR ACTnR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS® <br />Megan Mitchell <br />BUSINESS NAMEPHONE <br />Elite IV Contractors <br /># <br />209 <br />EXT. <br />461-6337 <br />HOME Or MAILING ADDRESS <br />2535 Wigwam Dr <br />FAX# <br />( 209) <br />461-6342 <br />CITY Stockton <br />STATE Ca <br />zip 95205 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autnorizea agent or 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: _ Megan Mitchea DATE: 9/18/2017 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORizEDAGENT IR Office Assistant <br />%fAPPLICANT is nol 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. �Q)� <br />TYPE OF SERVICEREQUESTED' (,( r E/� <br />COMMENTS: say -'A ` J Z® SEP 19 2017 <br />y E)w,�o04" 1, <br />+q�R F 0"', ENVIRONMENTAL <br />N IRONM TAL HEALTH <br />tS C <br />ACCEPTED BY: to, EMPLOYEE #: DATE: / <br />ASSIGNED TO' 0 ; EMPLOYEE M () DATE: <br />Date Service Completed (if alre6dy completed): SERVICECODE: P i E: 2309 <br />Fee Amount: (, Amount Pale (>(� Payment Date <br />Payment Type i,SD-- Invoice # Ch #� tj� 17 Rec Ived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />