Laserfiche WebLink
` V L MAIM ��. <br /> APR 2 7 2016 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> o..� SERVICE REQUEST <br /> ype o usiness or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station V.Ck.,-7`}')q J <br /> OWNER/OPERATOR <br /> Ron Patel CHECK If BILLING ADDRESS <br /> FACILITY NAME ARP MINI MART CORP <br /> SITE ADDRESSS 95377-9717 <br /> 25775 Patterson Pass Rd Tracy <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# ,, II LAND USE APPLICATION# <br /> (209 ) 835-7777 9D4-1 Ibm4 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) cnp �-2 Cl� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Terry Masters CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Elite IV Contractors 209 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr (209 ) 461-6342 <br /> CITY Stockton 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 WPARTMFNI'hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN I-N' Ordinance Codes,Standards,STATE:and FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: ca4.z-�, wkz - DATE: 4/27/16 <br /> PROPF.RT1'/I3USINFSSO\4'NF.IL❑ OPERATOR/NIANAGER ❑ OTnERAt7Tn0RIzFDA(;EVI q Office Manager <br /> If APPLICANT is not the B11,1.1,V(;PARTY,proof of authorilation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner of 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 to the SAN JOAQUIN COI)Nll' ENVIRONMENTAL HFAIA11 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: 5 Gallon Bucket Replacement 0� j 1 )eTL-117- IJ/Ay ivi Li`'I I <br /> COMMENTS: See Violation dated April 11,2016 <br /> REeEivEb- <br /> APR 2 8 2016 <br /> SAN JOAQUIN COUNT" <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: 'I <br /> ASSIGNED TO: EMPLOYEE M DATE: 4- :;[/—/ <br /> Date Service Completed (if already co leted): SERVICE CODE: `! 9 P!E: <br /> L <br /> Fee Amount: f Amount Paid Payment Date y <br /> Payment Type 5� Invoice# Che?;ic# Received By: 7 ' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />