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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t` 1 <br /> Retail L� t .-1 <br /> t-. <br /> OWNER/OPERATOR <br /> Chacko Thomas CHECK If BILLING ADDRESS <br /> FACILITY NAME Emils Liquor <br /> SITE ADDRESS 1405 California St Escalon `2SA <br /> Street Number Direction Street Name Cit 9 Z3 C�Ee�1 elo <br /> HOME or MAILING ADDRESS (If Different from Site Address) ECVEp <br /> Street Number Street Name 1EI <br /> CITY STATE ZIP UG 2018 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# E JOAQUIN OU <br /> NTy <br /> (209 ) 499-2693 �2 H Ili n-M N7AL <br /> PHONE#2 EXT. BOS DISTRICT LOCA IO CODE rMENT <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECKIf13ILLINGADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx# <br /> g (209 ) 461-6342 <br /> CITY Stockton STATE Ca ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <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. l(Qp <br /> �( <br /> APPLICANT'S SIGNATURE: DATE: �/ <br /> PROPERTY/BUSINESS OWNER OPERA-(1/111/MANAGER ❑ OTHER Al T110RIZED AGENT® Office Assistant <br /> If APPLICANT is not the BILLIAIG PARTF,proof of authorization to sign is required Tule <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 ENVIRONMEN-FAL HEALTH DEPARTMENT as soon as it is available atd a S e me it is <br /> provided to me or my representative. tR <br /> TYPE OF SERVICE REQUESTED: 1 I127 - <br /> COMMENTS: <br /> De? <br /> ACCEPTED BY: EMPLOYEE M DATE: y , <br /> ASSIGNED TO: �e OBJbcvr <br /> 4 <br /> EMPLOYEE M DATE: O <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 0 <br /> Fee Amount: (,� Amount Pai IL�j v� Payment Date 7 d <br /> Payment Type ! Invoice# cChhk# / ��j� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />