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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel FSC 0/ � � S� (P <br /> OWNER / OPERATOR <br /> Jeet Sandhu CHECK if BILLING ADDRESS <br /> FACILITY NAME Manteca Liquor & Food <br /> SITE ADDRE990 N Main St . Manteca 95336 <br /> O Street Number Direction Street Name City Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) SAME <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> (209 ) 2394550 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 765-2619 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT. <br /> 09 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209 ) 461 -6342 <br /> CITY Stockton STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT: 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 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 : Cam )yDATE : 5/31 /2023 <br /> PROPERTY I BUSINESS OWNER 13 OPERATOR I MANAGER OTHER AUTHORIZED AGENT El 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 , 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/FSnrovided to me or <br /> my representative. r //0 y <br /> JAC <br /> TYPE OF SERVICE REQUESTED : u v ` R&Y7' v - C� <br /> COMMENTS : SB - J <br /> tl OsqN ?423 <br /> hEA TH 'O MFIVOUNTY <br /> RTtijFNT <br /> ACCEPTED By@ IEMPLOYEE #: DATE: Z Zai <br /> ASSIGNED TO : � S'1 EMPLOYEE M DATE: (./9 Z 2 :3 <br /> Date Service Completed (if already completed) : SERVICE CODE: PIE:All 23C� <br /> Fee Amounts ( P F" Amount Pal vo Payment Date 1017123 <br /> Payment Type I &A _ Invoice # Check # 11p3 �'j51� +�� Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />