Laserfiche WebLink
SAN JOAQUIWOUNTY ENVIRONMEN'T'AL HEALTIT 1PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF -CA, 000 D <br /> OWNER/OPERATOR CHECK if BILLING ADDRESSO <br /> FACILITY NAME LJS Gasoline <br /> SITE ADDRESS 749 1 ECharter Way Stockton 95206 <br /> street Number Direction Street Name City Zip Code <br /> F ol%E or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE Al EXT. APN# LAND USE APPLICATION# <br /> { 209 ) 465-8979 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REtQUESTOR Carl Wayne Henderson C14ECKifBILLING ADDRESS <br /> ® <br /> BUSINESS NAME PHONE# EXT. <br /> APEC <br /> 209 467-7573 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 55105 (209 ) 943-3003 <br /> CITY Stockton STATE CA ZIP 95205 <br /> MILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENV[RONMI:NTAL 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 JOAQ(JIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE'. 11/14/10 <br /> PROPERTY/BUSINESS OWNER© OPERATOR I MANAGER 0 OT'nE.R At THORIZED AGENT® Authorized Agent <br /> ffAPPLIC4NT is not the BILLIArG PARTY proof of authorization to sign is required fitte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 HEAIJI I DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. YMF—N <br /> TYPE OF SERVICE REQUESTED: V S� (S <br /> COMMENTS: ATG (TLS-350) crashed. Coldstart and certify <br /> OO <br /> SAN- icVL T <br /> E11VI�D�PAFITI�OAOSI 'hE�T <br /> �Epy._fH <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: V LTY\ EMPLOYEE#: 1 DATE: r <br /> Date Service Completed (if already compieted): SERVICE CODE:! P i E: <br /> Fee Amount: ed Amount Paid �2 {d ,D Payment Date L1 <br /> Payment Type Invoice# Cheek# �Q� Received By: Z <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />