Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Dispensing Facility Fl Y <br /> Flow U 0j��5 <br /> OWNER / OPERATOR <br /> Flyers Energy, LLC D CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> Flyers #427 <br /> SITE ADDRESS <br /> 3300 Waterloor Rd . Stockton 95205 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) <br /> Street NumberE Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sarah Jablonsky-Construction Manager CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Walton Engineering , Inc. 916 373- 1165 <br /> HOME or MAILING ADDRESS FAx # <br /> �P�OyBox 1025 ( 916 ) 373- 1172 <br /> West Sacramento STATE CA ZIP 95691 <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 /> 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 : ) /I DATE : 1 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Construction Manager <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 pmvided to me or <br /> my representative . h'AY <br /> TYPE OF SERVICE REQUESTED : / is <br /> ��? CES <br /> COMMENTS: <br /> SAN FEB 102021 <br /> E JOAQUIN <br /> HEALTH CEPA TrA N Y <br /> ME <br /> N <br /> ACCEPTED BY : -l/ C� �� [���J EMPLOYEE #: DATE : ; <br /> ASSIGNED TO : �%;S� "�t�� �� �� EMPLOYEE #: DATE : <br /> C;V 2X <br /> Date Service Completed ( if already completed ) : SERVICE CODE: / (7, S PIE , 230 <br /> Fee Amount: aL' Amount Pai L1<7D� Payment Date92111A <br /> Payment Type Invoice # Check # S S Received By : <br /> II <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />