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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prop e FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> Sunny CHECK if BILLING ADDRESS ® <br /> FACILITY NAME French Camp 76 <br /> SITE ADDRESS 5777 S French Camp Rd Stockton 95206 <br /> Street Number Direction Street Name CIN Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #'I ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 983-4781 � 2` (� 1 �l <br /> PHONE #2 Exr. 1 I l. 0 BOS DISTRICT LOCATION.CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan CHECK If BILLING ADDRESS <br /> an Mitchell <br /> BUSINESS NAME Elite IV Contractors PHONE # ExT. <br /> 209 461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX # <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 . <br /> APPLICANT' S SIGNATURE : DATE : 1 /21 /2020 <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 isvided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : �� T �/ — f G pra <br /> COMMENTS : <br /> wilz <br /> J/4 � 2020 <br /> SAN <br /> JOA�UIN C NTy <br /> HEA TH EPgR <br /> Nr <br /> ACCEPTED BY : EMPLOYEE #: DATE: 2 W <br /> ASSIGNED TO : C 1 J EMPLOYEE #: DATE : I <br /> Date Service Completed ( if already completed) : SERVICE CODE : PIE: ,9,50q <br /> Fee Amount : Paid - � 5a UD Payment Date <br /> Payment Type W Invoice # Check # �U3 Received By : ZA <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />