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SAN JOACIUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> `Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> A �r > q�6 e � � OS45 <br /> OWNER / OPERATOR <br /> Jeet CHECK If BILLING ADDRESS <br /> FACILITY NAME Manteca Liquor & Food <br /> SITE ADDRESS 890 N Main St Manteca 95336 <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 [AP7N # LAND USE APPLICATION # <br /> ( 209 ) 765-2619 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr Stockton Ca 95205 ( 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 andlor 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 : DATE * �r�( <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT LI 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 tlbl, Or <br /> my representative . om <br /> fii/o � n <br /> TYPE OF SERVICE REQUESTED : ; <br /> COMMENTS: <br /> FpgR�F QTY <br /> _ r <br /> ACCEPTED BY : r Ila EMPLOYEE #: DATE : <br /> ASSIGNED TO : , Jl �� EMPLOYEE M DATE : f� <br /> Date Service Completed ( if already completed) : <br /> SERVICE CODE : ( PIE : - $� <br /> Amount Paid 7�� v � Payment Date <br /> Fee Amount : (L <br /> Payment Type Invoice # Check # :707/, � '7 Received By : / <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />