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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station v, t obb';t-� �) �JKCsJ-li(p I�510 <br /> OWNER/OPERATOR <br /> 7-Eleven Inc. CHECK It BILLING ADOREss❑ <br /> FACILITY NAME 7-Eleven#17334 <br /> SITE ADDRESS 4501 N Pershing Ave. Stockton 95207 <br /> Street Number I Dire N n I Cil ZI coCe <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Slreet Name <br /> CITY STATE IIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> I III 01-70C)4 <br /> ( ) <br /> PHONE#2 ET. BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK l f BILLING ADDRESSLaJ <br /> BUSINESS NAME PHONE# Ez. <br /> Walton Engineering, Inc. (916)373-1167 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (916)373-1173 <br /> CITY West Sacramento STATE CA ZIP 95620 <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, STATE/and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Fle0DATE: 10/27/16 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 Contractor <br /> If APPLICANT IS not the BILLING PARTY,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 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 avallabie and at the same time it IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: h'/i{RF 'MF <br /> COMMENTS: V <br /> � FQ <br /> N o <br /> h r&P'V19, <br /> fey <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: M ` ` EMPLOYEE#: DATE: <br /> Date Service Completed (if already ompleted): SERVICE CODE: q PIE: <br /> Fee Amount: LA` Ov Amount Paid 7 QD Payment Date 1 <br /> Payment Type Invoice# Check If S/5� Received By: i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />