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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S` )CE REQUEST# <br /> l <br /> Retai , C 01. ()!3 <br /> OWNER I OPERATOR <br /> Rupi Padda CHECK If BILLING ADDRESS <br /> FACILITY NAME Bills 76 <br /> SITE ADDRESS 633 E Victor Rd Lodi 95242 <br /> Street Number Direction Street NaMe City <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip OEC <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# AN d0 ,� <br /> (209 ) 814-3581 ENVIRpti/N CqJN7y <br /> ExT. BOS DISTRICT LOCATION RT C <br /> PHONE#2 NT <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr ( 209 ) 461-6342 <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 <br /> or 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 Pawls. <br /> APPLICANT'S SIGNATURE: /%/�� L /�� C/f DATE::, I I ci 113C/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 11 F C 9 2018 <br /> ENVIRONMENTAL HE TH <br /> � <br /> DEPARTMENT <br /> ACCEPTED BY: w /� '"Lc EMPLOYEE M DATE: ,I /i <br /> 'al. ,� o is <br /> ASSIGNED TO: n om_ EMPLOYEE M DATE: 11-1q <br /> 1_1 <br /> Date Service Completed (if already completed): SERVICE CODE: 16( s PIE: 30 <br /> Fee Amount: . Amount Paid 4116G-O6 Payment Date <br /> Payment Type Vi�� I Invoice# Chplk# 9SYBDI 77 1 Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />