Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas & Food Retail q (0a SQ <br /> OWNER / OPERATOR <br /> ML <br /> ILTJl /j /`? /��i, ,� A OOo CHECK if BILLING ADDRESS <br /> 1FVACILfiTY NAME Abdo Nashir dba National (Ptroleum <br /> SITE ADDRESS 713N EI Dorado Street Stockton 95202 <br /> Street Number Direction I Street Name City Z11) 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 /> ( 209 ) 235 -6262 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Deborah Jones CHECK If BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Drive ( 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 <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 : 6/ 10/2021 <br /> PROPERTY / BUsINESSOWNER ❑ OPERATO / ANAGER ❑ OTHER AUTHORIZED AGENT ® Administative Assistant <br /> IfAPPLICAAFT 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 . <br /> TYPE OF SERVICE REQUESTED, S ' T It Pq(�y <br /> COMMENTS : /1 V �( , � j Z C e/rVL1 /� <br /> (� C JUN r <br /> 10 2021 <br /> Sq N`i�gQU/N C <br /> Hj�gAL HRONMFNrUNTy <br /> ACCEPTED BY : <br /> EMPLOYEE <br /> #: DATE: <br /> ASSIGNED TO : L05 &?9G�64 t EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed) : SERVICECODE: lqf 2ePIE <br /> 2we <br /> Fee Amount : d o � Amount Paid Payment Date <br /> Payment Type Invoice # Check # % <br /> Received By : <br /> xoi, S <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />