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8AN JOAQUIN COUNTY Il i\IVIRONIUIVNTAL HEALTH DEPARTMENT <br /> ) F, f V1GE RI= QIUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail A woo n 094 GIs; <br /> OWNER / OPERATOR Hari Kambo <br /> 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME One Stop <br /> SITE ADDRESS 1151 Louise Ave Manteca 95336 <br /> 1151 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 /> ( 20Q 8234081 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 20q 8234081 <br /> CONTRACTOR It SERVICE REQUES7I OR <br /> REQUESTOR Carrie Miller CHECK If BILLING ADDRESSIZ <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209 461 -6337 <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 /> also certify that I have prepared this pli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , Standards , TATk and FEDERAL laws . <br /> APPLICANT' S SIGNATURE : F ` �/C DATE : 12 /21 /21 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Manager <br /> If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , 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 assessruent information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS IIY�I,B ,p� <br /> my representative . � V ! ( J �l � <br /> TYPE OF SERVICE REQUESTED : � � IAZ-j�a- 7 <br /> COh7IdENTS : � � /� � � .yam S, /\l/ NV �02 <br /> S Y J AN iO <br /> COtJN <br /> HEALTH <br /> EPA TTA y <br /> ✓l E T <br /> ACCEPTED BY : /r r , I ellvL EMPLOYEE M DATE : <br /> ASSIGNED TO : ICTAL CI( f 5; EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE IqO 7 ao; PIE : � � <br /> Fee Amount : �*w Amount Pal L fs� 00 Payment Date Z3 <br /> Payment Type , Invoice # Check # 136 3eD Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />