Laserfiche WebLink
Rrug 07 15 07: 21a Elite Iv Contractors Inc 2094616342 P. 8 <br /> SAN JOAJ% COUNTY ENVIRONMENTAL HEALAARTMENT J <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station <br /> OWNER I OPERATOR <br /> Rinku Singh CxccRii Bauxc ADOREss❑ <br /> FACILITY HANE <br /> Charter Way Chevron <br /> SITE ADDRESS 508W Charter Way Stockton 95205 <br /> stmel Namber Dimctian Street Name city Zip Code <br /> HONE or MAILING ADDRESS (If Different from Site Address) <br /> Simet Number <br /> CITY STATE ZIP <br /> PHONE#t LANO USE APPLICATION# <br /> i ) <br /> PHONE#Z - BOS DISTRICT LOCATION C004 <br /> i ) <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller cxEeKif BEUNG ADOREss12 <br /> BUSINEss NAME PHONE# <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: I, the undersigned property or business owner,operator or authorized agent of same, <br /> acknowledge that all site and/or project specific LN iRoNTme,TAL HEALTH DEPARThtNT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this Corm. <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 JOAQutN <br /> COUNTY Ordinance Codes,Standards, STy('Eand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t .t%�. 6��.t 1 J2� L/LZ 1 DATE: 7124/15 <br /> PROPERTY/Blistv'EAOwNERO OPERATOR/MANAGER ❑ OTHERATrrnoRizia)AGEATO OfficeMamnger <br /> 1fAPPLic wT is not the B,7-r.AG PA R7F proof of authorization to.sign is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,t,the owneror operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geolochnical 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: Drop Tube 87 Tank#1 <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (N already completed): SEWICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check#yrs Received By: <br /> EEVISED 1/1 R E r E I V SR FORM(Golden Rod) <br /> REVISED 102x5 03 REGEIV��rf hha�wwww■��..•.+dd� <br /> AUG 0 7 2015 <br /> ENVIRONMENTAL. <br /> Jce• IJ r`COgOTAACkIT <br />