Laserfiche WebLink
r <br /> SAN JOAQUOOUNTV ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> gasoline dispensing facility <br /> OWNER/OPERATOR <br /> FA7-Eleven, Inc. <br /> Ty�� El <br /> CHECK 11 BILLING ADDRESS <br /> G�IrNaeven Market #2368 / Store #32190 <br /> SITE ADDRESS 4943 South State Route 99 <br /> Stockton 95206 <br /> Street Number Direction Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) Cit" Zip cone <br /> 2339 Gold Meadow Way, Suite 101 <br /> L.IT, Street Number Street Name <br /> Gold River STATE Zip <br /> CA 95670 <br /> PHONE#1 EXT. APN# <br /> ( ) LAND USE APPLICATION# <br /> 17931001 <br /> PHONE#2 EXT. <br /> ( I BOS DISTRICT LOCATION CODE <br /> REQUESTOR CONTRACTOR / SERVICE REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering, Inc . �g <br /> P��6 373-1152 EX,. <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 1025 (9161 373-1172 <br /> CITY West Sacramento STATE CA <br /> ZIP 95691 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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, STA E d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � ��lu �S rA <br /> DATE: <br /> PROPERTY/BUSINESS OWNERC OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> /fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 HEALTH DEPARTMENT as soon as It is available and at the Sante time It is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: <br /> PIE: <br /> Fee Amount: Amount Paid <br /> Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />