COMPLIANCE INFO 2013-2015 - Laserfiche WebLink

Home Browse Search

SA JOAQbfirCOUNTY ENVIRONMENTAL HEALTH Li'`PARTMENTFIL F ;, CJ Y SERVICE REQUEST Type of Business or Property CHECKlf BILLING ADDRESS® FACILITY ID # SERVICE REQUEST # Gas Station HOME or MAILING ADDRESS --I 40. 0 70 1;140 610sl- OWNER/OPERATOR OWNER/OPERATOR CHECKIf BILLING ADDRESS To r Energy Group FACILITY NAME DATE: f / Tower Mart #104 SITE ADDRESS 192 1 EMPLOYEE #: •l�b� / l+ Lathrop Lathrop 95330 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Di4ferent from Site Address) Amount Paid 3 Street Number Street Name CITY STATE ZIP PHONE#f Exr• APN# LAND USE APPLICATION# ( ) ' ICIG -•I�-0l PHONE #2 ( ) En. BOS DISTRICT LOCATION CODE 1 CONTRACTOR/ SERVICE REQUESTOR r REQUESTOR I Veronica Freitas CHECKlf BILLING ADDRESS® BUSINESS NAME Walton 1 %gineering, Inc. Ezr. PHONE #373-1167 HOME or MAILING ADDRESS --I 40. BOX 1025 FAX# (916)373-1173 CITY West Sacramento 11 STATE CA ZIP 95691 activity will be billed to me I also certify that I have p COUNTY Ordinance Codes, APPLICANT'S SIGNAT PROPERTY / BUSINESS OWNI If APPLICAf site address, hereby authc to the SAN JOAQUIN COUNTY my representative. [ENT: I, the undersigned property or business owner, operator or authorized agent of same, project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or business as identified on this form. red this application and that the work to be performed will be done in accordance with all SAN JOAQUIN adards, STATE and FEDERAL laws. - S'/G.r.~•.7''nrr o.� l>t�� S! DATE: I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Contractor not the BILLING PARTY proof of authorization to sign is required Title BE INFORMATION: When applicable, I, the owner or operator of the property located at the above the release of any and all results, geotechnical data and/or environmental/site assessment information VIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time It i5 provided t0 me Or TYPE OF SERVICE REQUESTED: u S PAYMPUr COMMENTS: i RECEIVED- JAN 3,0 2014 saH JOAQUIN COU NTY EM'IRGNN L HEALTH DEPAR MENT ACCEPTED BY: 9e n WI EMPLOYEE #:`1 i .7 D DATE: f / ASSIGNEDTO: EMPLOYEE #: •l�b� / l+ DATE: Date Service Completed (if z (ready completed): SERVICE CODE: PIE: •-vQ v Fee Amount -2 7 Amount Paid 3 Payment Date Payment Type Invoice # I Check # T%S�d Received By. EHD 48-02-025 07/17/08 SR FORM (Golden Rod)