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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> Praveen ParaShar CHECK if BILLINGADDRESs <br /> FACILITY NAME Tracy 76 <br /> SITE ADDRESS 95377 <br /> W. Grant Line Rd <br /> YT racy <br /> 2420 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 # y LAND USE APPLICATION # <br /> ( 209) 830 - 1139 a- /& I <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR ' ICE REQUESTOR <br /> REQUESTOR <br /> Olivia Marie OjedaV/ CHECKifBILLING ADDRESS <br /> BUSINESS NAME ElitelV ContractorsZ ( 209 461 m6337 <br /> PHONE # EM <br /> HOME Or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209 461 -6342 <br /> CITYStockton STATE CA zIP 95205 <br /> BILLING ACKNOWLEDGEMENT: I , the\unu9lrsigned property or business owner, operator or authorized agent of same , <br /> acknowledge that all site and/or project spec C NVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed tome or my business as i ntified on this form . <br /> also certify that I have prepared this applic Ion that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, Ste" 4L llaws <br /> APPLICANT' S SIGNATURr 1 DATE : 6-21 -2019 <br /> PROPERTY / BUSINEP ' ❑ OTHER AUTHORIZED AGENT ❑ Service Coorinator <br /> authorization to sign is required Title <br /> AUT ' Iicable, I , the owner or operator of the property located at the above <br /> sitE 's , geotechnical data and/or environmental/site assessment information <br /> to th as soon as it is available and at the same time it is provided to me or <br /> my re, <br /> TYPE OF <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE #: I[ DATE: elfil <br /> ASSIGNED TO : EMPLOYEE #: Q U j 'J DATE : 40 <br /> Date Servic Compli. . , ,seted) : SERVICE CODE: / 9 P l E s� <br /> Fee Amo nt: Amount Paid Payment Date <br /> Paym t Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />