Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station 4r <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Quik Stop Markets Inc . <br /> FACILITY NAME <br /> Quik Stop #124 <br /> SITE ADDRESS 505 N Main St. Manteca 95336 <br /> Street Number Direction Street Name City TZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 165 Flanders Rd . <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Westborough MA 01581 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �+�n1{ <br /> Walton Engineering , Inc - Veronica Freitas CHECK If BILLING ADDRESS13 <br /> BUSINESS NAME PHONE # EXT, <br /> Walton Engineering , Inc 916 373- 1166 <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . Box 1025 , West Sacramento , CA 95691 ( ) <br /> CITY Manteca STATE CA ZIP 95336 <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 . <br /> APPLICANT ' S SIGNATURE : � � DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT QJ Contractor <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 to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> ACCEPTED BY: EMPLOYEE # : DATE : <br /> ASSIGNED TO : EMPLOYEE # : DATE: <br /> Date Service ompleted ( if already completed) : SERVICE CODE : PIE : <br /> Fee Amount : Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />