COMPLIANCE INFO_2013-2017 - Laserfiche WebLink

Home Browse Search

SAN JOAQUI*UNTY ENVIRONMENTAL HEALTH DITMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Station Min Mart_� gRa67 'JQ � J OWNER/ OPERATOR Quik Stop Markets CHECK If BILLING ADDRESS❑ FACILITY NAME EXT. Quik Stop #125 ACCEPTED BY: SITE ADDRESS W HOME or MAILING ADDRESS Date Service Completed (if already completed): 6/9/16 Ripon 95366 158t}SVeet Number ® Main St Street Name 461-6342 Ci i Code HOME or MAILING ADDRESS (If Different from Site Address) Check # r/0 / 73 Received By: Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( 800 ) 972-0982 1 av171 DC10 '�L.-% PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( 209 ) 599-4261 CONTRACTOR / SERVICE REQUESTOR REQUESTOR j p CHECK If BILLING ADDRESS Carrie Miller ,ry BUSINESS NAME PHONE # EXT. Elite IV Contractors ACCEPTED BY: 209 461-6337 HOME or MAILING ADDRESS Date Service Completed (if already completed): 6/9/16 FAX# SERVICE CODE: 2535 Wigwam Dr Fee Amount: V 0 ( 209) 461-6342 CITY Stockton STATE CA ZIP 95205 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. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN J0AQt11N COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: �'1*1 DATE: 6/10/16 PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ O"rHr..R AUTHORIZED AGENT 6/10/16 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 HF.At.Tti DEPAR'rMENT as soon as it is avail4leka d a th -M tIa it is i , provided to me or my representative. . C TYPE OF SERVICE REQUESTED: Replace 87 Leak Detector j p JUN 10 201 COMMENTS: ,ry SUN Z 3 2016 SAN " -°i w ! t_ ACCEPTED BY: EMPLOYEE M AI 1 Fi DEPAR7 ATE: i ASSIGNED TO: EMPLOYEE #: DATE: _II ':5_, J Date Service Completed (if already completed): 6/9/16 SERVICE CODE: P I E:� Fee Amount: V 0 Amount Paid Payment Date Payment Type �Sk- Invoice # Check # r/0 / 73 Received By: EHD 46-02-025 SR FORM (Golden Rod) REVISED 11/17/2003