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SAN JOAQUIN BOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> vicozanI 0 K� <br /> OWNER / OPERATOR <br /> Jay Ardass CHECK if BILLING ADDRESS ® <br /> FACILITY NAME Western Food and Fuel <br /> SITE ADDRESS 3032 Waterloo Rd Stockton 95205 <br /> Street Number Direction Street Name City Zin 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 /> ( 209 ) 346-9232 <br /> PHONE #2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # ExT, <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr <br /> ( 209 ) 461 -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 : f`%�'- - DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / 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 ar above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessmentinfllFINg "' 1 g <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time it is prov ��'I1Ba � p <br /> my representative . / I� I <br /> TYPE OF SERVICE REQUESTED : JUS 0 �F9 <br /> COMMENTS : OAQU/N C lJ <br /> Fier <br /> VIN EN NTY <br /> H DEPART ENT <br /> ACCEPTED BY : \ �� �' EMPLOYEE # : '/CEJ DATE : <br /> f <br /> ASSIGNED TO : /��� y� EMPLOYEE # : ` - DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE : q , P IE4 <br /> Fee Amounts Amount Pald _ 'KS Payment Date 73 <br /> Payment Type vii _ Invoice # Check # Received By : SL <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />