Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> 6a.4 Jit pp b i3a oag I I W co. <br /> OWNER / OPERATOR <br /> Rupi Padda CHECK If BILLING ADDRESS <br /> FACILITY NAME Country Side Mini Mart <br /> SITE ADDRESS 14971 N Hwy 88 Lodi 95240 <br /> Street Number Direction Street a 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 ) 914-8735 <br /> PHONE #2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK if BILLING ADDRESS ® <br /> BUSINESS NAMEPHONE # ExT , <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS Fax # <br /> 2535 Wigwam Dr <br /> ( 209 ) 461 -6337 <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 /> 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 : ��2 DATE : � ` !/u //Gr' <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR 1 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 /> t0 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 . P <br /> A Val <br /> TYPE OF SERVICE REQUESTED : ��� t �/ i v • l ft / <br /> COMMENTS: <br /> SANSFP 2119 <br /> EN AQUI <br /> HEAL y NMFNTU �Y <br /> EP RTM C <br /> r <br /> ACCEPTED BY: � ' / EMPLOYEE #: / C; DATE; F1711 ef <br /> ASSIGNED TO : �jJ Jpv ��� EMPLOYEE M DATE : <br /> Date Service Completed ( if already completed) . SERVICE CODE: C7P TE a5cc <br /> Fee Amount : r� Amount Paid $ t � _ Payment Date 11 9 <br /> Payment Type SA Invoice # ICheck # Received By: L <br /> w " ' <br /> fL , q � 8qa 7 7 q / 101 i q <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />