COMPLIANCE INFO_2006-2013 - Laserfiche WebLink

Home Browse Search

SAN JOAQU*OUNTY ENVIRONMENTAL HEALTIREPARTMENT SERVICE REQUEST Type of Business or Property Retail Fuel FACILITY ID # �S� CHECK If BILLING ADDRESS SERVICE REQUEST # ��c-) o 6 D& -7S OWNER/ OPERATOR Quik Stop Market, Inc. P CHECK if BILLING ADDRESS❑ FACILITY NAME Quik Stop #39 Ro�ME��AL H�pEpaRTNENT PERMIT/'SERVICES FAX# 016) SITE ADDRESS 2285 Street Number E Direction Fremont Street Street Name ZIP 95691 Stockton city 95205 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street NumberF Street Name CITY Fee Amount: 3 �� ) STATE ZIP PHONE #1 EXT. ( 519 657-8500 APN # Payment Type ✓i LAND USE APPLICATION # PHONE #2 EXT. Check #'1 301 1 `E• S BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Covan COMMENTS: CHECK If BILLING ADDRESS BUSINESS NAME Walton Engineering, Inc. p�G 2 3 2010 AUG 1 6 A'10 P 373-1166 Err. HOME or MAILING ADDRESS P.O. Box 1025 Ro�ME��AL H�pEpaRTNENT PERMIT/'SERVICES FAX# 016) 373-1173 CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, 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. 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 COUNTY Ordinance Codes, Standards TE and FEDERAL laws. APPLICANT'S SIGNATURE: ti\— _� DATE: - \3 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[; Compliance Manager 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: (-S% OUILAVtAT _ COMMENTS: Rer,y4sD c— p�G 2 3 2010 AUG 1 6 A'10 ENVIRUNlIAENT HEALTH Ro�ME��AL H�pEpaRTNENT PERMIT/'SERVICES ACCEPTED BY: a 1r Z �� EMPLOYEE #: DATE: (F ASSIGNED TO: w o k) 6- EMPLOYEE #: 7�/ DATE: 0 Date Service Completed (If already completed): SERVICE CODE: P I E: Fee Amount: 3 �� ) Amount Paid 3 0 0 Payment Date 73 (c7 Payment Type ✓i Invoice # Check #'1 301 1 `E• S Received By: EHD 48-02-025(( ` `� / SR FORM (Golden Rod) REVISED 11/17/2003 W.