Laserfiche WebLink
SAN JOAQUIN '"OUNTY ENVIRONMENTAL HEALTT" 11EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel a �"� <br /> OWNER/OPERATOR <br /> Bill and Cathy Norby CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Waterloo Shell <br /> SITE ADDRESS 4315 E Waterloo Road Stockton 95215 <br /> Street Number I Direction Street Name Citf Zit)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# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEEXT. <br /> Walton Engineering, INc . P"�"�� 373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( 916) 373-1172 <br /> CITY West Sacramento STATE CA ZIP 95691 <br /> BILLING ACKNOWLEDGEMENT: I, 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 FEDERALlaws. <br /> I <br /> APPLICANT'S SIGNATURE: 1�t,,e�— DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ff Compliance Manager <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 Sly 1s me time it is <br /> provided to me or my representative. PAY,��_ F 0 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: MAS <br /> IN COuNN <br /> SAN 30 aoNME lMENT <br /> S TN VIE-? <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ` y PIE: <br /> Fee Amount: Amount Paid ?,�S Payment ate 5- <br /> Payment Type ✓ Invoice# Check# M301 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />