Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> 00 <br /> OWNER / OPERATOR <br /> Paul Tiwana CHECK if BILLING ADDRESS <br /> FACILITY NAME Tiwana Gas & Food <br /> SITE ADDRESS 1210 E Hammer Ln Stockton 95210 <br /> Street Number Direction Street Name Citv Zip 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 /> ( 209 ) 715-0124 <br /> PHONE #2 Exr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # ExT' <br /> 209 461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAx # <br /> CITY Stockton STATE Ca 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 Or <br /> activity will be billed to me or my business as identified on this form (HER <br /> also certify that I have prepared this application and that the workperformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, SCTATE� d E L laws . <br /> APPLICANT'S SIGNATURE : ` � ' DATE : <br /> PROPERTY <br /> BUSINESS OWNER ❑ OPERA FOR I MANAGER ❑ AUTHORIZED AGENT ® Office 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 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 . p � <br /> TYPE OF SERVICE REQUESTED :EIQo <br /> COMMENTS: G lRCEZu �t® <br /> S <br /> SEP 17 2019 EP 16 2019 <br /> SANJOAQUINCOUN ENVIRONMENTAL H ;_ Ai_ r {-{ <br /> ENVIRONMENTgN PERMIT / SERVICES <br /> HEALTH L <br /> ACCEPTED BY: V EMPLOYEE M a 747 <br /> DATE: ` / 67 <br /> r <br /> ASSIGNED TO : Pa O EMPLOYEE M LIQ DATE q11 / <br /> Date Service Completed ( if already completed) ' SERVICE CODE: / P I E:� <br /> Fee Amount: 5& Amount Paid 45wZ, Payment Date Cj 1 �7 / I <br /> Payment Type Invoice # Check # f u , Zq l f. 1P ! Received By :ISA <br /> � ltVIL9 <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br /> i <br /> I <br />