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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST # <br /> PAW ( � ` 5 <br /> OWNER / OPERATOR <br /> Jawinder Singh CHECK if BILLING ADDRESS <br /> FACILITY NAME JD Service Station <br /> SITE ADDRESS9015 W Walnut Grove Rd Thornton 95686 <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 ) 794 -8993 <br /> PHONE #2 Ex-r. BOS DISTRICTLOCATION CODE <br /> ( ) 00 � Cl � � <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE # ExT. <br /> Elite IV Contractors ( 209 ) 461 -6337 <br /> HOME Or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 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 /> 1 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 : 7 / <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / fffANAGER ❑ OTHER AUTHORIZED AGENT ® fflce 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 provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> SA IV J t/ 20l <br /> OA <br /> N� CTH DR q F�✓TA�N 1° <br /> RTIyFN <br /> ACCEPTED BY : EMPLOYEE # : DATE : �S � � t ` i <br /> ASSIGNED TO : 1 � � EMPLOYEE # : DATE: /, �S � 0 ( " <br /> Date Service Completed (if already completb : SERVICE CODE: ' PIE: <br /> Fee Amount : Amount Pal4lhLry O Payment Date IbIl <br /> Payment Type t Invoice # Check # e72 � 0 t3 Rec Ived By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />