Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Convenience Store <br /> OWNER I OPERATOR <br /> 7-11 CHECK if BILLING ADDRESS <br /> FACILITY NAME 7-11 <br /> SITE ADDRESS 770 WStockton 95206 <br /> Street Number Direction Charter WayStreet Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CnY STATE ZIP <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> ( 559) 432-6744 1 163-230-23 BP19-08030 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Robert Vermeltfoort CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> VAI 559 432-6744 1 <br /> HOME or MAILING ADDRESS 8525 N. Cedar, Suite 106 FAX# <br /> CITY Fresno STATE Ca zIP 93720 <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 nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE:i2 DATE: 4-8-2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORzED AGENT Architect <br /> If APPLICANT is not the BILLING PARTY proof of authorization to Sign iS re[Iaire 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 is <br /> provided to me or my representative. C R 7 <br /> TYPE OF SERVICE REQUESTED: j�/(�/p S -�_ <br /> 11 <br /> COMMENTS: y[, SSAAI JO 8 <br /> y�A t HCEPgRTMEN <br /> ACCEPTED BY: C(A.6tV It 4, Cd EMPLOYEE#: DATE: 8 - '2-0 <br /> ASSIGNED TO: �..�V\ ��v'C- EMPLOYEE#: DATE: Lt <br /> l -Fr-lo <br /> Date Service Completed (if already completed): SERVICE CODE: —23 P 1E: <br /> Fee Amount: 49";"t, Amount Pai QVOT Payment Date <br /> Payment Type ��J Invoice# Check# q Received 8y: <br /> EHD 48-02-025 PI'S} 1 "r" "°I SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> S <br />