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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station 0My-::2-q <br /> OWNER/OPERATOR <br /> 7-Eleven, Inc. CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> 7-Eleven#32190 <br /> SITE ADDRESS 4943 S CA-99 Stockton 95215 <br /> Street Number I Dir tin Street Name city ZIo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> Walton Engineering, Inc. (916)373-1-166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( )916 373-1171 <br /> CITY West Sacramento 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: DATE: <br /> � a 10/23/18 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT M 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it IWip�r'ovided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: _ C <br /> COMMENTS: S'9 O � <br /> 90, <br /> h�c�ITV�R QUA 10,8 <br /> 14 <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE#: I Q` DATE: R -3o' I <br /> ASSIGNED TO: �rl� 1� EMPLOYEE#: 1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: itl <br /> Fee Amount: Amount Paid �� Payment Date /1 V <br /> Payment Type Invoice# Check# S<f0r Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />