Laserfiche WebLink
SAN JOAd* COUNTY ENVIRONMENTAL HEALTOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SE RVICE REQUEST # <br />Gas Station <br />BUSINESS NAME <br />Walton Engineering, Inc. <br />EMPLOYEE #: <br />OWNER / OPERATOR <br />CHECK If <br />Tower Energy Group <br />BILLING ADDRESS <br />FACILITY NAME <br />Tower Mart #104 <br />P.O. BOX 102$ <br />SITE ADDRESS 192 <br />2-2L) <br />1 Lathrop <br />STATE CA ZIP 95691 <br />Lathrop <br />95330 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 En. <br />APN # <br />LAND USE APPLICATION # <br />t ) <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Veronica Freitas <br />CHECKIf BILLINGADDRESS® <br />BUSINESS NAME <br />Walton Engineering, Inc. <br />EMPLOYEE #: <br />PHONE# E . <br />ASSIGNED TO: <br />EMPLOYEE #: <br />916 373-1167 <br />HOME or MAILING ADDRESS <br />FAX# <br />P.O. BOX 102$ <br />Fee Amount: <br />2-2L) <br />Clio West Sacramento <br />STATE CA ZIP 95691 <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 />I 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: <br />DATE: <br />PROPERTY/BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor <br />If APPLICANT is not the BILLING PARK proof of allthorization 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 assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided t0 me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />