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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> 00 0 6133 4� 03'OL 60 <br /> OWNER / OPERATOR <br /> Rupi Padda / Bikram CHECK If BILLING ADDRESS <br /> FACILITY NAME Georges Mini Mart <br /> SITE ADDRESS 18662 N HWY 88 Lockeford 95237 <br /> Street Number Direction Street Name City 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 /> ( 209 ) 814-0300 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # ExT'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 /> 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 . 11Z APPLICANT' S SIGNATURE : � 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 at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it IS provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : j Pi41� HENT � ' �� <br /> COMMENTS : REC EIVED <br /> APR 0 8 2019 APR � 4 2019 <br /> SAN JOAQUIN COUNTIENVIRONMENTAL HEAL. <br /> ENVIRONMENTAL <br /> FPARTMFNI <br /> ACCEPTED BY: zo�o EMPLOYEE # : � (�� � DATE: Lfgi ) <br /> LV I <br /> ASSIGNED TO : Mau-u', EMPLOYEE # : DATE: � � i2d q l <br /> Date Service Completed (if already completed) : SERVICE CODE : Qy PIE: �g <br /> Fee Amount: , Amount Paid Payment Date ' g / 97 <br /> Payment Typ Invoice # Check # ( Wo g91 S , e, Tg Received By : 1�6 <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />