COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # statio ��- `�' Tank Ti ht coas J I�l. HOME Or MAILING ADDRESS FAX# 8515 Waterman Rd ( ) OWNER / OPERATOR CHECKIf BILLING ADDRESS Husain FACILITY NAME Circle K SITE ADDRESS EMPLOYEE #: s main st manteca �� 419 Street Number Direction DATE:�Y� Street Name Date Service Completed city ZIp Code HOME or MAILING ADDRESS (If Different from Site Address) SERVICE CODE: ! IY — %� PlE:�� Fee Amount: �� Street Number Amount Paid Street Name CITY STATE ZIP PHONE#1 ExT• APN# # 2 D 5� LAND USE APPLICATION# ( 409) 292 5953 PHONE#2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR /SERVICE REQUESTOR 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. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 06/23/2021 PROPERTY/ BUSINESS OWNER ❑ OPERATOR !MANAGER ❑ OTHER AUTHORIZED AGENT X❑ Contractor If APPLICANT is not the BILLING PARTY proof of a at%V" t0 Slvir IS IV4 ed 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 env ironmental/site assessment information 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 my representative. TYPE OF SERVICE REQUESTED:�ry REQU ESTO R CHECK If BILLING ADDRESS Tony Mehroke BUSINESS NAME PHONE# ExT' Tank Ti ht ( ) 916 753 0177 HOME Or MAILING ADDRESS FAX# 8515 Waterman Rd ( ) CITY Elkgrove STATE ZIP 95624 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. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 06/23/2021 PROPERTY/ BUSINESS OWNER ❑ OPERATOR !MANAGER ❑ OTHER AUTHORIZED AGENT X❑ Contractor If APPLICANT is not the BILLING PARTY proof of a at%V" t0 Slvir IS IV4 ed 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 env ironmental/site assessment information 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 my representative. TYPE OF SERVICE REQUESTED:�ry EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 COMMENTS:q ,_/ (� t� 0 202 SA jork NE O x. rvoil"NtAEN tlCNt-11111"', ACCEPTED BY: r V EMPLOYEE #: DATE: ASSIGNED TO: �� EMPLOYEE#: DATE:�Y� Date Service Completed (if already Completed): SERVICE CODE: ! IY — %� PlE:�� Fee Amount: �� �' Amount Paid Payment Date Payment Type Invoice #C # 2 D 5� Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08