Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Market spoklo <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 7 Eleven 14113B <br /> SITE ADDRESS <br /> 3040 W Benjamin Hol Dr, Stoc ton,CA 95219 <br /> Street umber Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Mailing/Billing address: P.O. Box 219088,Dallas,T4tZNAer Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ez . APN# LAND USE APPLICATION# <br /> ( 209-)478-3040 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( 209I337-8943 11 7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> BENHOLT SE INC. (209-J78-3040 <br /> HOME Or MAILING ADDRESS FAx# <br /> 2142 Saddlebrook St ( ) <br /> CITY STATE ZIP <br /> Stockton,CA 95209 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 10/20/2020 <br /> 2o�bir s�mA1 <br /> PROPERTY/B USINESS OWNER® OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. Pz <br /> A, <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Oct <br /> Sq 2020 <br /> N�gQUINC <br /> // Nt;gLTHOSPA 1-AL <br /> ACCEPTED BY: EMPLOYEE#: U,C/` DATE: 0 rJ/'1 <br /> ASSIGNED TO: EMPLOYEE#: ll�J ?A DATE: C) 121' 'Z `^ , <br /> Date Service Comple d (if already completed): SERVICE CODE: P/ .� ` y <br /> Fee Amount: Amount Pai /S Payment Date 1b ZD <br /> 152.00 1524 1 <br /> Payment Type Ce el` Invoice# Check# 11Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �0 A N 031 <br /> Doc ID:2d48ba28c75a39a8b5d90b08d7a53033544543eb <br />