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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 /> Rupi Padda CHECK if BILLING ADDRESS <br /> FACILITY NAME Country Side Mini Mart <br /> I <br /> SITE ADDRESS 14971 N Hwy 88 Lodi 95240 j <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> I <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209 ) 814 -0300 � � i �� � ✓ <br /> PHONE #2 EXT. BOS DISTRICT E j <br /> CONTRACTOR / SERVICE REQUESTOR <br /> I <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS <br /> i <br /> BUSINESS NAMEPHONE # EXT, <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESSFAX # <br /> 2535 Wigwam Dr <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 <br /> 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 : <br /> �y <br /> PROPERTY / BUSINESS OWNER ❑ OPERATO / 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 provided t0 me Or J <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : j , S t <br /> COMMENTS : wit IV <br /> v8v <br /> saN Z019 <br /> N FNVIROIV COIN ry <br /> I <br /> ACCEPTED BY : EMPLOYEE # : DAT . p r r I <br /> ASSIGNED TO : EMPLOYEE M DATE : <br /> I <br /> Date Service Completed (if already completed ) : SERVICE CODE: L PIE: ' � U ,J i <br /> Fee Amount : 7 Amount Paid Payment Date 67/ 1 <br /> 3 / � <br /> Payment Type Invoice # Check #611 � � l 3 25 Received By : <br /> EHD 48 -02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />