Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GAS STATION WITH CONVENIENCE STORE 5 96 3 <br /> OWNER I OPERATOR <br /> (ANNIE) GURPREET SANDHU CHECK if BILLING ADDRESS© <br /> FACILITY NAME CIRCLE K <br /> SITEADDRESS 2115 WEST YOSEMITE AVENUE MANTECA95337 <br /> Street Number Di---— I Street Name city-, 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 /> { 925 )785-2000 198-017-028 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <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 <br /> or 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: DATE: 2/1/2021 <br /> PROPERTYIBusiNEssOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® ENGINEER <br /> IfAPPLICANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. �jPA <br /> TYPE OF SERVICE REQUESTED: l�y� '1 <br /> COMMENTS: <br /> s.�N 10 <br /> d�-i- c el y Fti�4yo° tv � <br /> 4 QZJ <br /> EA4EpgRN <br /> Ty0 <br /> ACCEPTED BY: 67 4 a ' EMPLOYEE#: - DATE: <br /> ASSIGNED TO: EMPLOYEE M ���9 DATE: 2//1124 <br /> Date Service Comp <br /> "toted (if already completed): SERVICE CODE: 2 3 E: <br /> Fee Amount: Amount P 1 �� Payment Date 16, <br /> Payment Type Invoice# Check# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />