Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # MMSERVICE REQUEST # <br /> Fuel dispensing station <br /> WNER I OPERATOR CHECK If BILLING ADDRESS <br /> kk <br /> FACILITY NAME Cruisers 76 <br /> SITE ADDRESS W Lathrop Rd Manteca 95336 <br /> 1137 Street Number Dlrectlo Street Name CIty ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 1. Street Namo <br /> CITY STATE ZIP <br /> PHONE #1 EXT, ApN # LAND USE APPLICATION # <br /> j0� 11 (Pon <br /> HONE #2 Exr• BOS DISTRI T 11 iLOCATION C DE <br /> ( ) V <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR BZ Maintenance Cm5cKIfBILLING ADDRESS ❑ <br /> PHONE # E xT' <br /> BUSINESS NAME BZ Maintenance ( 916 ) 371 �2380 <br /> HOME Or MAILING ADDRESS PO Box 933 Fax # <br /> ( ) <br /> clTv W Sacramento STATE CA ZIP 95691 <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& q cel <br /> XAPPLICANT' S SIGNATURE : DATE : <br /> PROPERTY I BUSINESS OWNER ❑ OP RATOR I MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the B14LING PARTY, proof of authorization to sign is required Titre <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 environmentallsite as� e t information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same timei�� Or <br /> my representative. �T <br /> TYPE OF SERVICE REQUESTED' �Yt7 <br /> COMMENTS: SAA1 JO Z�Z� <br /> Remove (3) straight drop tubes . Install (3) drop tubes with flappers . Test with county . H��NT/Ro UMECO � y <br /> HDEPJT L <br /> ACCEPTED BY: sTdC'G ��/� EMPLOYEE #: DATE : Iy 4 <br /> ASSIGNED TO : pa&Ys+ 0 EMPLOYEE Its DATE: ilf <br /> /q Z <br /> Date Service Completed ( if already completed) : -� SERVICE CODE: 9g qp Pt E: 009 <br /> Fee Amount: � � Amount Paid , 6� Payment Date Z2 A <br /> l Z <br /> Payment Type I Invoice # Check # 13 20/ aZ� Receive By : <br /> EHD 48.02-025 SR FORM (Golden Rod) ' <br /> 07/17/08 <br />