Laserfiche WebLink
SAN JOAQUI0OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GAS STATION :: FA0003847 c /�/ 7 -495 <br /> OWNER/OPERATOR d� v� w <br /> Lori Toccoli - executor- DBA WESTLANE FUELS estate of Jay McIlratihHECKIf BILLINGADDRESS❑ <br /> FACILITY NAME WESTLANE FUELS <br /> SITE ADDRESS N WEST LANE STOCKTON 95204 <br /> 3300 Street Number I Direcuon Stmet Name city Zip Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO BOX 326 Street Number Street Name <br /> CITY STATE ZIP <br /> STOCKTON CA 95201 <br /> PHONE 81 ExT. APN# LAND USE APPLICATION# <br /> (209 ) 466-1681 <br /> PHONE#2 EZT. BOS DISTRICT LOCATION CODE <br /> (209 ) 462-8707 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> LORI TOCCOLI CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EZ . <br /> WESTLANE FUELS Ong ) 462 8707 <br /> HOME or MAILING ADDRESS FAX# <br /> PO BOX 326 (209 ) 462-6171 <br /> CITY Stockton STATE CA ZIP 95201 <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 hav repare applicatio7y�nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance odes,Standards, T "and FE RAL 1,WS. <br /> APPLICANT'S SI NATURE: D TE: 8/30/16 <br /> PROPERTY/BUSINESS NERL'7 OPERAT /MANAGER OTHER AUTHORIZED AGENT❑ Owner/executor <br /> If APPLI not the BILL/NG ARTY proof of au rization to sign is required true <br /> AUTHORIZATION TO RELEASE INFORMATION: When apple I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotec nical 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 twe it is <br /> provided to me or my representative. ft AV c <br /> lo <br /> TYPE OF SERVICE REQUESTED: (�1 �1r'� rlt:CF VES <br /> COMMENTS: (JSAN JO 3O Z016 <br /> CIVICkirlq� U�3 OLwe� yf NV O4 g1JNry <br /> FIyT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed if already completed): SERVICE CODE: C, Il PI E: <br /> Fee Amount: I Amount Paid /39,(� Payment Date <br /> Payment Type Invoice# Check# IS121 Rece' ed By: <br /> EHD 25 ` O SR FORM(Golden Rod) <br /> REVISEDSED 11 11/17/2003 �,/ <br />