Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERV GE REQUEST <br /> Type of Business or PropertyL yl� �Tl FACILITY ID # SERVICE REQUEST it <br /> Gas Station F�Doode S ►� ® � v . F <br /> OWNER / OPERATOR <br /> Rupi Padda CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Plaza Liquor & Gas <br /> SITE ADDRESS 2420 W Turner Rd Lodi 95242 <br /> Street Number Direction Street Name Cltv Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• API # LAND USE APPLICATION # <br /> ( 209 ) 369- 1960 <br /> PHONE #2 ExT• BOS DISTRICT -�JLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # ExT, <br /> 209 461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX # <br /> ( 209 ) 461 -6342 <br /> CITY Stockton STATE Ca ZIP 95205 <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 : 2&4Lr L DATIE�: <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / kANAGER ❑ OTHER AUTHORIZED AGENT LI Office Assistant <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required Till e <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 IS provided t0bWOr <br /> my representative . I"� W <br /> TYPE OF SERVICE REQUESTED : S� �� C � ' <br /> COMMENTS: Q('� <br /> Y <br /> 4VJ OWN <br /> ENV�gC�/N <br /> H�CTN PO MR A�� <br /> ACCEPTED BY : J � Q �jy EMPLOYEE # : �,/ DATE: <br /> ASSIGNED TO : `� v � EMPLOYEE #: �/ 3 DATE : <br /> Date Service Completed (if already Completed) : SERVICE CODE : PIE: <br /> Fee Amount : tj „ Amount Paid 6 , v (D Payment Date <br /> Payment Type iS '�`,�' Invoice # Check # 17LISZx Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod) <br /> 07/17/08 <br />