Laserfiche WebLink
SAN JfJA(.:KIIN C9OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel 90 707 J � DO Sc5o Zk <br /> OWNER / OPERATOR <br /> Jivtesh Gill CHECK If BILLING ADDRESS <br /> FACILITY NAME Arch Arco AM PM <br /> SITE ADDRES85 S HVVY 99 Stockton 95215 <br /> 4tS Street Number Direction I Street Name CRY Zip 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) 948-2438 2l190S <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209 948 -2438 W � D 4 <br /> CONTRACTOR / SERN710E RE, QUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT, <br /> 209 461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209 ) 461 -6337 <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> also certify that I have prepared this app ication an that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , Standards, ST E and FEDERAL laws. <br /> V <br /> APPLICANT ' S SIGNATURE : [ �� DATE : 3/8/2�- <br /> PROPERTY f BUSINESS OWNER ❑ OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT ® Office Manager <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it IS provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : T {� PYi�' f Al <br /> COMMENTS : 6 <br /> A ry <br /> tdogQ <br /> y�A4T N114 <br /> OEAgR� T4 NTY <br /> ACCEPTED BY : ve ✓7 EMPLOYEE #: DATE : 3117/ 7 <br /> ASSIGNED TO : V EMPLOYEE #: DATE : <br /> Date Service Completed' '( tf already completed) : _ SERVICE CODE : /r _2 of P / E:,eZO <br /> Fee Amount : L� —� Amount Paid DU Payment Date 3 Z� <br /> Payment Type Vi Invoice # Check # 14 C kD y735- Recely d By,Sal <br /> ly-DS�F7 S� <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />