COMPLIANCE INFO 2010 - 2014 - Laserfiche WebLink

Home Browse Search

SAN JOAQU —"OUNTY ENVIRONMFNTAL HEALTI EPARTMENT SERVICE REQUEST Type of Business or Property ,pie--7?LO FI l FACILITY ID # SERVICE REQUEST # Retail Fuel PHONE# ExT. ACCEPTED BY: '5r—m 5il 1 3 y OWNER/OPERATOR 7 -Eleven Inc CHECK If BILLING HOME or MAILING ADDRESS ASSIGNED TO: ADDRESS FACILITY NAME 7 -Eleven #2369-19976 P.O. Box 1025 SITE ADDRESS 1399 N Main Street STATE CA Manteca 95337 Street Number Direction Street Name u / Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Check # U�53 Street Number Street Name CITY STATE ZIP PHONE #f EXT_ APN # 2 c 4e - 3- LAND USE APPLICATION # ( I ►O -.3 PHONE #2 EXT. ( ) BOS DISTRICTS LOCATION ODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Webb ,pie--7?LO FI l CHECK If BILLING ADDRESS BUSINESS NAME Walton Engineering, Inc. PHONE# ExT. ACCEPTED BY: L ( V1 G (916)373-1166 EMPLOYEE #: 2 HOME or MAILING ADDRESS ASSIGNED TO: FAX # P.O. Box 1025 DATE: rC� (916)`373-1173 CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards TE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE:�U PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Manager If APPLICANT is not the BILLING PARTY', proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: (e` -r— ,pie--7?LO FI l RtVt=��✓�I.� COMMENTS: SAN JOAOUINE oul'o ENVIRONM HEALTH DEPARTMENT ACCEPTED BY: L ( V1 G EMPLOYEE #: 2 DATE: / q 0 ASSIGNED TO: , EMPLOYEE #: DATE: rC� Date Service Completed (if already completed): SERVICE CODE: q O P 1 E: Ce Fee Amount: _ 3 c'C Amount Paid u / Payment Date Payment Type ✓ Invoice # Check # U�53 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003