Laserfiche WebLink
SAN JOAQUAOUNTY ENVIRONMENTAL HEALTH SARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Veronica Freitas <br />SERVICE REQUEST # <br />Gas Station <br />(' <br />i I <br />j Zm 73�'L c---,� <br />OWNER / OPERATOR <br />(916)373-1167 <br />HOME or MAILING ADDRESS <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />P.O. Box 1025 <br />Shell <br />(916)373-1173 <br />SITE ADDRESS <br />STATE CA zip 95620 <br />P I E! <br />Fee Amount: �J(i pa0 <br />Amount Pai <br />3q0. U6 <br />1612 <br />W <br />Hammer Lane <br />Invoice # <br />Stockton <br />95209 <br />Street Number <br />Direction <br />Street Name <br />CityP <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #t EXT•APN <br /># <br />LAND USE APPLICATION # <br />( ) <br />X3'7 7 Z1; -"W -,-)- <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />00a <br />01 <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />Veronica Freitas <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />OCT 162 <br />ENVIRONMENTAL <br />PERMITJRFRV <br />PHONE # ExT• <br />Walton Engineering, Inc. <br />EMPLOYEE #: <br />(916)373-1167 <br />HOME or MAILING ADDRESS <br />FAX# <br />P.O. Box 1025 <br />Date Service Completed (if already completed): <br />(916)373-1173 <br />CITY West Sacramento <br />STATE CA zip 95620 <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 or <br />activity will be billed to me or my business as identified on this form. <br />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: A'2(6� DATE: 10/14/15 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 13 Contractor <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />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 <br />my representative. <br />TYPE OF SERPAYWIEWED: S <br />COMMENTS: RECEIVED <br />�OCT 162015 <br />SAN JOAQUfN COUNTY <br />ENV1 RO N M ENTAL <br />HEALTH DEPARTMENT <br />OCT 162 <br />ENVIRONMENTAL <br />PERMITJRFRV <br />ACCEPTED BY:W <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: 7(X i� Pe <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: I C <br />P I E! <br />Fee Amount: �J(i pa0 <br />Amount Pai <br />3q0. U6 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By:a <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />fED <br />115 <br />HEALTH <br />CES <br />