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SAN JOAQUIN COUNTY U. NVIRONMENTAL HEALTH DEPARTMCNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> S�-f—GLfi � 7Pc DO (:) B — 6 <br /> OWNER / OPERATOR <br /> Ashish Boveja CHECI( If BILLING ADDRESS <br /> FACILITY NAME My Mini Mart <br /> SITE ADDRESS 1756 N Wilson Way Stockton 95205 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Streot Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 408 ) 204- 1636 <br /> PHONE 42 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE RE' QUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS ® <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 : 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 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 la $ of . <br /> APPLICANT' S SIGNATURE * / ' , �f � (/ �� DATE : 7/7/2020 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I 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 , 1 , 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 provided t0 me or <br /> my representative . P teiv <br /> A ' <br /> TYPE OF SERVICE REQUESTED : / Y T <br /> COMMENTS: // t D <br /> 84N J✓oV 0 ? ?o <br /> HF4 TN pQp FON NO ry <br /> qRT <br /> ACCEPTED BY : �- ` SMax 1� e EMPLOYEE #: c;\ gUw DATE: <br /> ASSIGNED TO : G � eYU EMPLOYEE #: w DATE: -\ A ZO <br /> Date Service Completed ( if already completed ) ; SERVICE CODE; ��� PI E: 'L �j <br /> Fee Amount : 4A9S Amount Paid Sly �� Payment Date 17120 <br /> Payment Type 6 5A� Invoice # Check # d 30 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />