COMPLIANCE INFO_2011-2016 - Laserfiche WebLink

Home Browse Search

S 0 rar Euviypul- , * - TE111 Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Station o 6 0 ,.6 ®O �0 0 & ct -7 OWNER /OPERATOR Walton Engineering, Inc. Flyers Energy, LLC. CHECK if BILLING ADDRESS FACILITY NAME Olympian #427 P.O. Box 1025 SITEADDRESS 3300 ACCEPTED BY: /,L�� ` Waterloo Road Stockton95205 DATE: v `P Street Number Direction EMPLOYEE #: dwf k? Street Name Cit ZI2 Code HOME or MAILING ADDRESS (if Different from Site Address) 2360 Lindbergh Street Fee Amount: 37 s Street Number Street Name CITY Auburn STATE CA ZIP Payment Type 95602 PHONE #t EXT. APN # Received By: LAND USE APPLICATION # ( ) lq;�- ISb -02 PHONE #2 EXT. BOS DISTRICT 'L1[ LOCATIOON/CODE ( ) 00 f_1 CONTRACTOR SERVICE REQUESTOR REQUESTOR E) Veronica Freitas CHECK if BILLING ADDRESS BUSINESS NAME I PHONE # EXT. Walton Engineering, Inc. (916)373-1167 HOME or MAILING ADDRESS FAX# P.O. Box 1025 ACCEPTED BY: /,L�� ` CITY West Sacramento -12.1613-D-1173 STATE CA ZIP 95620 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity Will be billed to me or my business as identified on this form. also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: &°uu'' A,-.Ze- DATE: 05130/14 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 12 Contractor If APPLICANT is not the BILLING PARTY. proof Of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: V` S COMMENTS: J/ f — I 2014 JE o '4 ACCEPTED BY: /,L�� ` EMPLOYEE #: Z6 '7 o DATE: v `P ASSIGNED TO: �^ EMPLOYEE #: dwf k? DATE: Date Service Completed (if already 41ornpleted): SERVICE CODE: t Q PIE: 7,309 Fee Amount: 37 s Amount Paid 37,— � Payment Date 6/4// Payment Type Invoice # Check # Received By: EHD 48-02-025 P SR FORM (Golden Rod) 07/17/08 [" G Z�