Laserfiche WebLink
SAN JOAQUWOUNTY ENVIRONMENTAL HEAL�EPARTMENT <br /> A SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GAS STATION LA Too Dai-_. �003S9y 3 <br /> — — <br /> O,VNER I OPERATORIf BILLING ADDRESS <br /> DDRESS <br /> o �o, _ _- - —_— <br /> F.. I RY ME - I 2 <br /> S i ADURES - <br /> �9 rn, _ City —_ Zi Code l <br /> 0,4w�l, V__Ktreet Numbe. OBection,� ree <br /> HOME or MAILI AD[I- fit Different from S(it1e Address) _ r <br /> _ y"40 Street Number <br /> CITY " TE <br /> PHONE#S _— Ezt� APN# LAND USE APPLIC.ITIOH# <br /> fl i 7 5�y� <br /> -- <br /> I °H9NE.,,[ Exr. BOS DISTRICT CATION CGDE <br /> _ CONI'RACTOR/ SERVI+ ;r. I;LEQUES'TOR <br /> REOt t:S' //� /- - CHECK if BILLING ADDRE=�S® <br /> � .# EXT. <br /> ;Otx_ INC. _ —1— �9—L4`-1-h337 <br /> HOME or MAILING ADLRE^3 PAX# ^ <br /> 2535 WIGWAM DRIVE (209 )461 -6342 <br /> CITYSTOCKTON STATE CA ZIP 95205 <br /> BILLING A-_,CNOWLF.DGEMENT: I,,the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge i'.r al' rite and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges as::ociated with this prn.;ect or <br /> activity will'-:,.billto me or nryb,,iergs as identified on this form. <br /> al,:() certify trial I have prepared tit?;application and that the work to be performed will be done in accordance:with ail SAN L;AQ,IIN <br /> Cot1NTY Ordinance "odes,Standa s, TE and F/EED[ER�AL laws. <br /> APPI`CANT'S SIGNATURE: fi l�°us----- DATE: .f1;16 /��1� )� <br /> PROPP-RTYi Bhiai P�.i OWN ER❑ .: OPERATOR/MANAGER OTIIER AUTHORIZED AGENT 4 �p /�// �/L `� <br /> IfAPPLICANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> infbrmatiotl 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. I PAYMENT <br /> TYPE OF SERVICE REQUESTED: S T RL p - RE <br /> COMMENTS: >Re,LCCGe 10V 10 <br /> Zon <br /> SM JOAQUIN COUNTY <br /> WRONMENTAL <br /> TH DEPARTMENT <br /> APPROVED BY: 1"/ EMPLOYEE lir ? DATE: <br /> ASSIGNEOTO: EMPLOYEE 8''38' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 PI E: LIB'C..YJ <br /> Fee Amount: 2 4j Amount Paid — Payment Date /( /B <br /> Payment Type Invoice# Check# `2; eceived By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> acxncFn A_s_m <br />