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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # ( / SERVICE REQUEST # <br /> t�Gb � 7 4&ke W J&;:E ;cS <br /> OWNER / OPERATOR <br /> CHECICif BILLING ADDRESS <br /> Heng Chea <br /> FACILITY NAME Waterloo Liquors <br /> SITE ADDRESS 2512 E Waterloo Rd Stockton 95205 <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 ) 607-5022 � L <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) to cl �! <br /> CONTRACTOR / SERVICE REi QUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT' <br /> 09 461w6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX # <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 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 IaWS . <br /> APPLICANT' S SIGNATURE : Ne&" DATE : . , 1 (00 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT IJ 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 t0 me Or <br /> my representative . T P <br /> EA <br /> TYPE OF SERVICE REQUESTED $ Mai <br /> Plot <br /> COMMENTS : JUN <br /> 1220, <br /> SAN j0AQU/N <br /> H�4CTH�pq� U fY <br /> ACCEPTED BY : ��1 EMPLOYEE #: DATE: <br /> ASSIGNED TO : EMPLOYEE #: DATE : <br /> Date Service Completed (if already complete : SERVICE CODE : wp� PIE <br /> Fee Amount : Amount Paid Payment Date W12L I <br /> Payment Type Invoice # Check # q,23 (pp � D �o Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />