Laserfiche WebLink
SERVICE REQUEST %* (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # V _l Z<I INVOICE # <br /> FACILITY NAME My Mini Mart BILLING PARTY Y / N <br /> SITE ADDRESS <br /> 1756 N Wilson Way <br /> CITY Stockton CA zIP 95202 _ ' <br /> OWNER/OPERATORAnnette Hoag BILLING PARTY Y / N <br /> PHONE #1 ( ) <br /> DBA <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # p Land Use Application # <br /> I805 Dist Location Code <br /> CONTRACTOR end/or <br /> SERVICE REQUESTOR James C. Bateman Petroleum Svc, Inc. BILLING PARTY Y / N <br /> DBA SEMCO PHONE #1 1209 ) 524A653 <br /> MAILING ADDRESS 1217 South 7th Street FAX # (909 <br /> CITY Modesto STATE CA ZIP 95351 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done� c dC rideR'with ell SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standard State and Federal laws. <br /> JUN 1 4 1 <br /> APPLICANT'S SIGNATURE II W'� <br /> SAN JOAQUIN COUNTY <br /> Title: Project Manager Date: 5/12/99 FNVIRONMENTAL HEATIH ICESDIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. �p <br /> Service Code ll I <br /> Nature of Service Request: <br /> Assigned to �1t�'U2 4"n <br /> ?C1✓"�.t`�.0 Employee # Date <br /> Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS CoI� 7,�_/ SUPV _/_/_ ACCT _/_/_ UNIT CLK _/_/_ <br />