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SAN JOAC) UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 3 MVICE RECUES �� <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST it <br /> OWNER / OPERATOR <br /> Mr. Swaren f< <br /> CHECIf BILLING ADDRESS <br /> FACILITY NAME K•& ;3 Gal & 1;ioc2rte� (� S67 Ca S' /✓( C� Fit <br /> SITE ADDRESS 701 E Charter Way Stockton F95206 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> P$N993- 129II ExT. APN # LAND USE APPLICATION # <br /> �1 { 12 Lam, <br /> PHONE #2 Exr. ) U iV Y BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 00 <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 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 /> 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 : WA91a4/ DATE : 10/28/2019 <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time it IS provldjW me or <br /> my representative . �Y"4 , <br /> hip <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: <br /> h' F/VVfROUINCO <br /> IJAN <br /> ACCEPTED BY : EMPLOYEE #: � DATE : �� lj m <br /> ASSIGNED TO : / J EMPLOYEE #: 690 DATE : ��J "Z / <br /> Date Service Completed ( if already completed ) : SERVICE CODE : <br /> Fee Amount: OC Amount Paid* (� 2 Payment Date Lb 47 <br /> Payment Type Invoice # Check # 7 772ZZ3� Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />