Laserfiche WebLink
SAN JOAQU: :OUNTY ENVIRONMENTAL HEALTI_ LPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Gas Station <br />CHECK if BILLING ADDRESS® <br />FACILITY ID # <br />O <br />Ir PAYMENT <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />Ted Guzman <br />FAx # <br />CHECK If BILLINGADDRESS� <br />FACILITY NAME <br />California Gas Station <br />( ) <br />CITY West Sacramento <br />SITE ADDRESS 1399 <br />Street Number <br />E <br />Direction <br />Yosemite <br />I Street Name <br />ASSIGNED TO: <br />Manteca <br />City <br />95336 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />SERVICE CODE: <br />Street Name <br />CITY <br />Amount Paid <br />STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />Re eived By: <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Veronica Freitas <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />Walton Engineering, Inc. <br />Ir PAYMENT <br />PHONE# EXT. <br />(916)373-1167 <br />HOME or MAILING ADDRESS <br />FAx # <br />P.O. Box 1025 <br />( ) <br />CITY 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 <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. <br />APPLICANT'S SIGNATURE: DATE: g l g s / Y r�%� <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® r•nntrart-_nr <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. <br />TYPE OF SERVICE REQUESTED: 571 <br />COMMENTS: <br />Ir PAYMENT <br />RECEIVED <br />OCT -1 2012 <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: o <br />Fee Amount: 3S r <br />Amount Paid <br />Payment Date !� A <br />Payment Type ✓ <br />Invoice # <br />Check # J � <br />Re eived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />