COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Ep FACILITY ID # SERVICE REQUEST# Gas & Food Retail CHECK If BILLINGADDREss F'A0002570 DATE: f Vii/ OWNER / OPERATOR EXT_ Cumberland Farms / EG America CHECK if BILLING ADDRESS❑ F4CILRYNAME Quik Stop 144 6 - 337 SITE ADDRESs7272S#OCktD Amount Pal !��_ FAX# Payment Type i5�� Invoice # 2535 Wigwam Dr C g� Received By: West Lane 461-63642 n 95210 Street Number Direction Streel Name c1tv 7Jp Code HOME or MAIUNG ADDRESS (if Different from Site Address) W, Thrid Street 302 Street Number Street Name CITY Cincinnati UI I TE ZIP 45202 -PHONE-#I -. ._. E"r. "APPuCAT10 ( 209} 952-8812 1--APN-#-tANv"Us PHONE #2 EXT. ( SOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Ep COMMENTS: Carrie Miller ACOEPTEDBY:S v1� s� (_4 �l CHECK If BILLINGADDREss BUSINESsNAME Elite IV Contractors DATE: f Vii/ PHONE# EXT_ DATE: I 20 6 - 337 HOME Or MAILING ADDRESS Amount Pal !��_ FAX# Payment Type i5�� Invoice # 2535 Wigwam Dr C g� Received By: ( 20� 461-63642 CITY Stockton STATEOA ZIP 95205 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, ST E nd FEDERAL laws. IIII,, ll APPLICANT'S SIGNATURE: a / / dllh' DATE: 11/24/2021 PROPERTYIBUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT B Offi ce M a nage r 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 environmentallsite assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 Soon as It is available and at the same time It me Or my representative, t7 1 fj/! N -r TY PE OF SERVICE REQUESTED: / X79 J Ep COMMENTS: V 3 (} 2021 COUNTYNv1RoNMHEa<r8 StDEPARMENr . ACOEPTEDBY:S v1� s� (_4 �l EMPLOYEE#: DATE: f Vii/ ASSIGNED TO:; /J v 0 EMALOYEE #: DATE: I Date Service Completed (if already completed): :5 SERVICE CODE: rlf f _hely PIE: Fye Amount:` 2 Amount Pal !��_ Payment Date 'n4l Payment Type i5�� Invoice # Check # I C g� Received By: EHE 48-02-025 SR FORM (Golden Rod) 07/17/08