Laserfiche WebLink
0 <br />SAN JOAQUIN COUNTY ENVIRONIRM�JARTMENT <br />SERVICE REUP-12 2016 <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS NAMEPHONE# <br />Elite IV Contractors <br />tit;A�� I�VIRONMENTAL HEAL <br />H &R2001 1g2J -7(p <br />Gas Station <br />V PERMITtSERO <br />OWNER/ OPERATOR <br />461-6342 <br />CHECK if BILLING ADDRESS© <br />Rupi Padda <br />ZIP 95205 <br />EMPLOYEE M <br />FACILITY NAME Flag City Shell <br />Date Service Completed (if already completed): <br />SERVICE CODE: SG <br />SITEADDRESS 6437 <br />P I E: 3d� <br />Banner St <br />I <br />Amountfl,al [f 7�� <br />Lodi <br />95242 <br />StreetNumberl <br />Direction <br />Che #/Zp�v <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />Zip <br />EXT. <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION <br /># <br />( 209 914-8735 <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Megan Mitchell <br />CFN <br />CHECK if BILLING ADDRESSEE] <br />BUSINESS NAMEPHONE# <br />Elite IV Contractors <br />209 <br />ExT. <br />461-6337 <br />HOME or MAILING ADDRESS <br />2535 Wigwam Dr <br />FAX # <br />( 209 <br />461-6342 <br />CI1r Stockton <br />STATE CA <br />ZIP 95205 <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 FEDERAL laws. <br />—�A� 12016 <br />/ <br />APPLICANT'S SIGNATURE: i'i'G17.�f'Ki DATE:: 081 1 / <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER 1:3 OTHER AUTHORIZED AGENT 11 Office Ice Assistant <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 the same time it is <br />provided to me or my representative. PA Vit. <br />TYPE OF SERVICE REQUESTED: Replace 87 Leak Detector <br />CFN <br />COMMENTS: <br />G 022016 <br />?2Q <br />6 <br />°C� <br />DC'� <br />ACCEPTED BY: f 'n L iotel J �n b <br />v` <br />EMPLOYEE M <br />(n <br />DATE: P-4 `C� <br />ASSIGNED TO: Al S Vel VkrV <br />EMPLOYEE M <br />DATE: Z <br />Date Service Completed (if already completed): <br />SERVICE CODE: SG <br />P I E: 3d� <br />Fee Amou �L17 6D <br />Amountfl,al [f 7�� <br />Payment Date <br />Payment Type I jam_ <br />Invoice # <br />Che #/Zp�v <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />