Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK IfBILLING ADDRESS 13 <br />FACILITY 1D # REQUEST%# <br />COMMENTS: <br />PHONE# EXT. <br />©SERVICE <br />ACCEPTED BY: <br />OWNER / OPERATOR <br />CITY Stockton <br />STATE Ca ZIP 95205 <br />ASSIGNED TO: _ <br />Rupi Padda <br />EMPLOYEE.#: <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Waterloo Shell <br />SERVICE CODE: <br />SITE ADDRESS 4315 <br />E <br />Waterloo Rd <br />5 OV <br />Stockton <br />% <br />95205 <br />Street Number <br />Diree <br />Street Name <br />Received y: <br />91tyCode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />treat Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT, <br />APN # <br />LAND USE APPLICATION # <br />( 209) 914-8735 <br />1 0'6-i 10 <br />PHONE #2 EXT. <br />( )lip <br />BOS DISTRICT <br />LOCATION CODE <br />99 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Megan Mitchell <br />CHECK IfBILLING ADDRESS 13 <br />BUSINESS NAME <br />Elite IV Contractors461-6337 <br />COMMENTS: <br />PHONE# EXT. <br />HOME or MAILING ADDRESS 2535 Wigwam Dr <br />9 <br />ACCEPTED BY: <br />FAx# <br />(209) 451-6342 <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 DEPARTMENT 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 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: f%JZ-��/ DATE: <br />PROPERTY/BUSINESS OWNER❑ OPERAT R/MANAGER ❑ OTHER AUTHORIZED AGENTIX Offir.P Assistant <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 <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 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: (� <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE 1 <br />�`1•� 1 <br />DATE: a_ _7—' ' <br />//— <br />ASSIGNED TO: _ <br />EMPLOYEE.#: <br />DATE: K- <br />Date Service Comipie?ecy (i aiready completed): <br />SERVICE CODE: <br />P I E: 3 <br />Fee Amount: <br />Amount Paid <br />5 OV <br />Payment Date <br />% <br />Payment Type <br />Invoice # <br />Check # -��l y'D3�s S <br />Received y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1 111 7/2 00 3 <br />