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SAN .IOAQUTr4 COUNTY ENVIRONMENTAL HEALTHTlEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDN SERVICE REQUEST It <br /> retail gas station FAt+- ocoaAlOL 5v*of>('q`� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> 7-Eleven, Inc . <br /> FACILITY NAME 7-Eleven #17334 <br /> SITE ADDRESS 4501 NPershing Ave . Stockton 95207 <br /> Street Number Ion Street Nam Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXr. APN# LAND USE APPLICATION# <br /> ( ) l 10lgao -1q <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK If BILLING ADDRESS El <br /> BUSINESS NAMEPHONE N EXT. <br /> Walton Engineering, Inc. <br /> HOME or MAILING ADDRESS FAx N <br /> P.O. Box 1025 ( ) <br /> CITYWest Sacramento STATE CA ZIP 95691 <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 /> 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,SATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: x% DATE: <br /> PROPERTY I BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® 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 /> t0 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. ra <br /> TYPE OF SERVICE REQUESTED: PA <br /> COMMENTS: <br /> JUL 2 4 M3 <br /> UINTY <br /> SANJO 1140 IN gr <br /> t{EALTH <br /> IF <br /> ACCEPTED BY: l� i C P^! L EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: (L4, ( <br /> Date Service Completed (if already completed): SERVICE CODE: 1 (iS P/L Z, 30 <br /> Fee Amount: ?�4 5% ,,) I Amount Paid � � Payment Date LQ,0 3 <br /> Payment Type Invoice# Check# O eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />