Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station6%00t1,7 <br />?v- <br />�' <br />OWNER/OPERATOR <br />209 <br />Swaran Chouchan <br />CHECK IfBILLING ADDRESS❑ <br />FACILITY NAME <br />2535 Wigwam Dr <br />Super Center Mart <br />( 209 ) <br />SITE ADDRESS <br />E <br />NVIROM <br />ACCEPTED BY: <br />95206 <br />701 Street Number <br />Direction <br />Charter Way <br />Street Name <br />Stockton,,,, <br />Zin Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SERVICE CODE: <br />P ! E. Z3 <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 EXT- <br />APN # <br />Payment Type (+ C <br />LAND USE APPLICATION # <br />( 209 ) 467-0305 <br />Check # <br />Received By:7�t(, <br />PHONE #2 ENT. <br />BOS DISTRICT <br />LOCATION CODE <br />(209) 993-1298 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Carrie Miller <br />CHECK If BILLING ADDRESS® <br />BUSINESS NAME <br />COMMENTS: <br />PHONE# EM <br />Elite IV Contractors <br />209 <br />HOME or MAILING ADDRESS <br />Fax # <br />2535 Wigwam Dr <br />( 209 ) <br />CITY Stockton <br />STATE Ca ZIP 95205 <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 DEPARTM>-N']' hourly charges associated with this project <br />or activity will be billed to me or ruy 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: Ca4A4�, NWAA' DATE: 6/22/16 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGF..NTLR Office Manager <br />If APPL/C.4NT is not the I3/LL1.yr, PARTY. proof of authorization to sign is required Tule <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 environniental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTMFNT 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: <br />Repair or replace failed annular sensor <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />, <br />COMMENTS: <br />VIECE1VED <br />JUN ti 2 Nis <br />JUS, 2 2 2016 <br />AQWN GOUN'1FY;� <br />. '' \ -"0,; T , <br />►�; �`�r1Y-` <br />SAN JO ENTAD <br />NVIROM <br />ACCEPTED BY: <br />EMP11*P . <br />DATE: 6 2 <br />ASSIGNED 70: <br />4r � � <br />EMPLOYEE #: <br />DATE: 16' <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P ! E. Z3 <br />Fee Amount: _ <br />Amount Paid .4? -3 9 p <br />Payment Date <br />Payment Type (+ C <br />Invoice # <br />Check # <br />Received By:7�t(, <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />