Laserfiche WebLink
SAN JOAQUIN f UNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SER01- . . ' QUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel F ;sq 7; Sf� c .,q � ,3 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS E] <br /> Christina Gill <br /> FACILNAME <br /> Vast Lane Lathrop <br /> SITE ADDRESS 116 E . Roth Road Lathrop 95330 <br /> Street Number I Direction Street Name city 7JP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 707) 326-0369 020 _ �,O <br /> PHONIER ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb CHECK If BILLING ADDRESS <br /> EXT. <br /> BUSINESS NAME Walton Engineering, Inc . P 373-1166 <br /> HOME or MAILING ADDRESS FAz# <br /> P.O. Box 1025 (916 ) 373-1173 <br /> CITY West Sacramento 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 <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. 'yt. <br /> APPLICANT'S SIGNATURE� DATrE: � I `—(c) <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LT Compliance Manager <br /> If APPLICANT 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 /> 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. D L <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAt't��PONIME MECtT <br /> H�ZH pEPAR <br /> ACCEPTED BY: O L-`V c t �� EMPLOYEE#: .� DATE: ( 4 f p <br /> ASSIGNED TO: tQ. EMPLOYEE#: J 2— DATE: ( [a (O <br /> Date Service Completed (if already completed): SERVICE CODE: Gt P 1 E: �(a <br /> Fee Amount: 3 cS 0--D Amount Paid 5 Payment Date \` kb <br /> Payment Type Invoice# Check# Z Received By:�f <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />