Laserfiche WebLink
SAN JOAACOUNTY ENVIRONMENTAL HEALTSDARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 7-Eleven#35355 <br /> SITE ADDRESS 3202 West ammer Lane Stockton 95209 <br /> Street Number Direction Street Name City Zip Code <br /> HQME or MAILING ADDRESS (if Different from Site Address) <br /> `� Street Number Street Name <br /> CIA STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECKif BILLING ADDRESSE] <br /> BUSINESS NAME PHONE# ExT. <br /> Walton Engineering, Inc. (916)373-1167 <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. Box 1025 (916)373-1173 <br /> CITY West Sacramento STATE CA ZIP 95620 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 <br /> ��and FEDERAL laws. <br /> // <br /> APPLICANT'S SIGNATURE: amu* -rll • DATE: 07-11-14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT [3 Contractor <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> 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 <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: PA <br /> COMMENTS: ECEry�D <br /> AUC <br /> �T <br /> ACCEPTED BY: EMPLOYEE#: DATE: / /q J y <br /> ASSIGNED TO: EMPLOYEE#: DATE: l l <br /> Date Service Completed (if already completed): SERVICE CODE: j•' P I E: ��' <br /> Fee Amount: Vii" i" Amount Paid 37� Payment Date //'1 <br /> Payment Type Invoice# Check# 43'2—+7 Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />