COMPLIANCE INFO_2016-2018 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIROUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST MAR 0 9 2016 Type of Business or Property ZCE/`/ FACILITY ID # Veronica Freitas SERVICE RyE'( EW Gas Station BUSINESS NAME % —755 PHONE # EXT. OWNER /OPERATOR DATE: 1-5- /w CHECK if BILLING ADDRESSO 7 -Eleven, Inc. HOME or MAILING ADDRESS PIE: a FACILITY NAME Amount Paictf P.O. Box 1025 7 -Eleven #32262 ( 916) 373-1173 SITE ADDRESS 2360 W I Grandine Road Tracy 95376 Street Number Direction Street Name City Zio Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number tr t Nam CITY STATE ZIP PHONE #1 EXT. ( ) APN # l LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICTLOCATION CODE ( ) ©` CONTRACTOR / SERVICE REQUESTOR REQUESTOR ZCE/`/ CHECK if BILLING ADDRESS Veronica Freitas ACCEPTED BY: BUSINESS NAME DATE: PHONE # EXT. Walton Engineering, Inc. DATE: 1-5- /w 916 373-1163 HOME or MAILING ADDRESS PIE: a FAX # Amount Paictf P.O. Box 1025 Payment Date 3 Y ( 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. 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: P.. A.e DATE: -3N h PROPERTY/ BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT a Contractor 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 t0 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. P TYPE OF SERVICE REQUESTED: ZCE/`/ COMMENTS: ��p92416 ��l pEP��tir,4L'�y ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: 1-5- /w Date Service Completed (if alrea y Completed: SERVICE CODE: PIE: a Fee Amount: CO Amount Paictf 376.,03 Payment Date 3 Y Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 -1�