Laserfiche WebLink
DAN JUAQUIN COUNT Y N-�31\! VIRONMENTAL HEALT I I DFIPARTMENT <br /> Type of Business or Property FACILITY It) iI SERVICE REQUEST it <br /> Retail Fuel t000i 001 � 7 / <br /> OWNER / OPERATOR CHECK If BILLING ADDRESSr11 <br /> Jas ' s Enterprise <br /> FACILITY NAME Woodbridge AmPm <br /> SITE ADD 4 b06Lower Sacramento Rd Woodbridge 95258 <br /> St=Numberection I Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 209 ) 339-8238 (� <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE RE QUEST'OR <br /> REQUESTORCarrie Miller CHECK If BILLING ADDRESS , <br /> BUSINESS NAME PHONE II Exr, <br /> Elite IV Contractors 209 461 -6337 <br /> HOME or MAILING ADDRESS FAx # <br /> 2535 Wigwam Dr (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 or <br /> activity will be billed tome or my busines - a identified on this form . <br /> also certify that I have prepared this pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , Standards STATE nd FEDERAL la s. <br /> APPLICANT' S SIGNATURE : DATE : 5/9/22 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / 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 Isded to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED ; u S / /'ZL� 7lAi �I <br /> l 'Z A ! <br /> COMMENTS : / V Q <br /> NF N1// Qu/,V '2 <br /> 6A/COM cNTy <br /> F/yT <br /> ACCEPTED BY . V �V �- EMPLOYEE #: DATE : 22 <br /> ASSIGNED TO : ) h /'� �� � L EMPLOYEE #: DATE: ;Z Z <br /> Date Service Completed ( if already completed) : / 0 Z!P SERVICE CODE: l9f,2gk PIE: 25C)e <br /> Fee Amount: i4o .t 4E Amount Paidqua, oz) Payment Date ? ? <br /> Payment Type Vl � � Invoice # Check # 1133IS 1 Received By : <br /> a jet/& 937 7 <br /> EHD 48.02.025 �d �e SR FORM ( Golden Rod ) <br /> 07/17/08 <br />