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Z»AN J OAOUIN (GOON 1Y [ NVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas & Food Retail 2 517 <br /> OWNER / OPERATOR <br /> Ernest Giannechini CHECKifBILLING ADDRESS ❑ <br /> FACILITY NAME Ernies General Store Inc . <br /> SITE ADDRESS4407 E . Waterloo Rd Stockton 95215 <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 ) 931 -2850 <br /> PHONE 42 E)cT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE It EXT. <br /> 209 (209 ) 461 -6337 <br /> HoME or MAILING ADDRESS 2535 Wigwam Dr FAxit <br /> ( 209 ) (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 applic ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT a d FEDERAL IaWS <br /> APPLICANT' S SIGNATURE : / U / WL DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Manager <br /> /f 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 ass ssment Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time WA(�yfoeo me Or <br /> my representative, I �� �V//� ��tlVmay <br /> TYPE OF SERVICE REQUESTED : #�Yn � L t <br /> COMMENTS : MAY 2 <br /> s 2021SAN j04 <br /> T <br /> HEgLyop7-NT <br /> Y A ENT <br /> ACCEPTED BY: r EMPLOYEE #: DATE : `� Z <br /> ASSIGNED TO : / v q ea h EMPLOYEE #: DATE: s„ <br /> & Y <br /> Date Service Completed ( if already completed) : SERVICE CODE : 1 " f f � P1Es `7 � <br /> Fee Amount: t ® � Amount Paid /�LRC�l Payment Date <br /> Payment Type � Invoice # Check # ZS $� d Received By. <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/17/08 <br />