Laserfiche WebLink
Is <br /> SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# C�SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Jivtesh Gill CHECK if BILLING ADDRESS <br /> FACILITYNAME 7-Eleven/76 Lodi <br /> SITEADDRESS 1111 E Kettleman Ln Lodi 95240 <br /> Street Number I Direction Street Name City Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 209 1 369-3633 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> l 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <br /> HMC- Henderson Maintenance Company 209 467-7573 <br /> HOME or MAILING ADDRESS FAx# <br /> PO Box 31325 L:IC4 i5lp-1-It (209 ) 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 /> -- <br /> APPLICANT'S SIGNATURE:(f A �awDATE: <br /> PROPERTY)BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization 10 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: or <br /> COMMENTS: Recurring ATG erroneous liquid &smart sensor alarms. PAYMENT <br /> RECEIVED <br /> NOV 2 0 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY:42 EMPLOYEE#: DATE: i 0 <br /> ASSIGNED TO: C EMPLOYEE M 2 DATE: <br /> Date Service Completed (if already comp) d): SERVICE CODE: PIE: <br /> 23,E <br /> Fee Amount: - L f�.CYO Amount Paid 3 — Payment Date a© 0 <br /> Payment Type Invoice# Check#(� Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />