Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CONVENIENCE STORE <br />PHONE# En. <br />530 755-4700 <br />HOME or MAILING ADDRESS <br />1000 Lincoln Road Ste. H2O2 <br />OWNER / OPERATOR <br />CITY Yuba City <br />Rupinder Dhillon <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Chevron <br />ASSIGNED TO: <br />SITE ADDRESS 1231N <br />EMPLOYEE M <br />Main Street <br />DATE: ':5- I . I —2 <br />Manteca <br />95336 <br />Street Number <br />Dlrec on <br />Street Name <br />Fee Amount: <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Addtess) 28214 <br />Leaf Drive <br />Street Number <br />Street Name <br />CITY Tracy <br />STATE Zip <br />CA 95304 <br />PHONE #1 Eu. <br />APN # <br />LAND USE APPLICATION # <br />(408-687-1492 <br />216-340-59 <br />PHONE#2 En. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Julio Tinajero <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Milestone Associates <br />C ku j'=& j ,EWT <br />PHONE# En. <br />530 755-4700 <br />HOME or MAILING ADDRESS <br />1000 Lincoln Road Ste. H2O2 <br />FAX # <br />( 530) 755-4567 <br />CITY Yuba City <br />STATE CA ZIP 95991 <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE:f� DATE: 5/t 611-1 <br />PROPERTY/ BUSINESS OWNER❑ OPERAtOR/MANAGER ❑ OTHERAUTHORIZED AGENT® <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 <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 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: C <br />C ku j'=& j ,EWT <br />COMMENTS: <br />f � <br />RECEIVED <br />MAf I5 2097 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HE H DEPARTMENT, <br />ACCEPTED BY: <br />EMPLOYEE <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: ':5- I . I —2 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />} <br />P 1 E: <br />Fee Amount: <br />Amount Paid <br />'I 1 7 . f u <br />Payment Date <br />I <br />Payment Type �lL <br />Invoice# <br />�T <br />Check# P\ 16 L_ <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />