Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Amended 6/08 /2021 Address Correction <br /> Type of Business or Property FACILITY ID # SE VICE REQUEST # <br /> rilGas & Food Retail T " 0 0 � g � �� I <br /> OWNER / OPERATOR <br /> Troy Embry / Facilities Manager CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> Super Store Industries <br /> SITE ADDRESS 16888 McKinely Avenue Lathrop 95330 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( if Different from Site Address) <br /> Street Number Street Nemo <br /> CITY STATE ZIP <br /> PHONE #t ExT. APN # LAND USE APPLICATION # <br /> ( 209 ) 858-3384 <br /> PHONE #2 EXT• BOS DISTRICT7LOCATION CODE <br /> ( 209 ) 858-3401 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Deborah Jones CHECK If BILLING ADDRESS X <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 /> F <br /> Stockton STATE CA ZIP 95205 <br /> BILLING ACKNOWLEDGEMENT : 1 , 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 : 6/02/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERAT / ANAGER ❑ OTHER AUTHORIZED AGENT Administrative Assistant <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1, 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 availablend at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED : S / HT fi C T <br /> COMMENTS: <br /> N <br /> sq /v9 ?p <br /> 44 // ' CO 21 <br /> �FpgR MENTY i <br /> ACCEPTED BY: � / GZ jV EMPLOYEE #: DATE: <br /> ASSIGNED TO : paeu Oc C) EMPLOYEE #: DATE : 1 !t � <br /> Date Service Completed ( if already completed) : SERVICE CODE: PIE: 230 <br /> Fee Amount: L� UU Amount Pa L]�-S[P Payment Date <br /> Payment Type Invoice # Check # f - Receiv d By : <br /> i <br /> EHD 48-02-025 j SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 1! <br /> 1 <br />