Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # nSERVICE REQUEST # <br /> GAS STATION F/-000 3 � q `/ ,,o 3K, 002H 2�- <br /> OWNER / OPERATOR SUNNY BHULLAR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME VALERO <br /> SITE ADDRESS 1700 EAST YOSEMITE AVENUE MANTECA 95336 <br /> Street Number Direction I Street Name c1tv 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 /> ( 408 ) 230-8999 22 62 072. <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 823-7676 : O <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR TONY MEHROKE CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME TANKJIGHT SYSTEMS , INC . P91E # 667-6891 Exr. <br /> HOME or MAILING ADDRESS FAX # <br /> 8515 WATERMAN ROAD ( ) <br /> CITY ELK GROVE STATE CA ZIP 95624 <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 /> 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 /> APPLICANT' S SIGNATURE : ID V�\-2! Vv���a � � DATE : 9/27/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® 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 . p <br /> TYPE OF SERVICE REQUESTED : U S � , - (� CC T <br /> COMMENTS : p/ Ci / � f!/ /,/ e& e C ra fj taz J�P <br /> C/ SqN ✓O ?O21 <br /> A <br /> NEA�TNOF q�NO�N Y <br /> TMF <br /> ACCEPTED BY: / v EMPLOYEE #: DATE: <br /> ASSIGNED TO : '� ` / (�� EMPLOYEE # : DATE : 7 � / <br /> Z4 9 <br /> Date Service Completed pn-eL( if already completed ) : `� SERVICE CODE : jff 2qe PIE: vO' <br /> Fee Amount : Amount Paid Payment Date <br /> Payment Type �i � Invoice # Check # Za35 3 Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />