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SAN 3OAQ U%IOUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> I <br /> ILITY ID# SERVICE REQUEST# <br /> GDF Q <br /> OVYNErt OPERATOit Jimmy CHECK if BILLING <br /> FACILITYNAME Alpha Fast Gas <br /> Stockton 95205 <br /> SITE ADDRESS 2358 E Waterloo Rd Zi Code <br /> Street Numtrer Direction <br /> Street Name City <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> STATE CA zip <br /> CITY <br /> EXT. APN# LAND USE APPLICATION# <br /> EPHONE#1BOSD95TRICT LOCATION CODE <br /> =#2EXT <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> FBUSINEss <br /> R Carl Wayne Henderson 343478 CHECK if_BILLINGADDRFSS� <br /> PHONE# EXT.. <br /> AME Service Station Testing-SST INC 209 465-5577 <br /> FAX# <br /> AILING ADDRESS PO Box 31465 ( 209 1 465-4988 <br /> STATE CA ZIP 95213 <br /> CIS' Stockton <br /> ACKNOWLEpGEMENT: undersigned property or business owner, operator or authorized agent of same, <br /> BILLING 1, the <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 /> 1 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 FEDE L laws. <br /> APPLICANT'S SIGNATURE: Cir--� � DATE: 1124113 <br /> ��{{ President <br /> PROPERTY/BUSINESS OWNERE] OPERATOR/MANAGER D OTHER AUTIIORIZED AGENT 111,1 <br /> If APPLICANT is not the BILLING <br /> PAR77,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 a5 SOOn as it 65 available and at t}l�}i�e time it 1S <br /> provided to me or my representative, IV <br /> •[Ty ^1]� <br /> TYPE OF SERVICE REQUESTED: JA 0, <br /> - <br /> COMMENTS: Replaced ECPU2, NVMEM and software after CPU board damage. FN04 s2Jr�� <br /> AIC 96' <br /> ACCEPTED BY: !EMPLOYEE#: DATE: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> Date Service Completed (if already completed): 1124113 SERVICE CODE: P J E:. <br /> Fee Amount: Amount Paid ; Payment Date v <br /> Payment Type Invoice# Check# �3 Rece ved By: <br /> EH❑48-02-025 f ; ko <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1 <br />