Laserfiche WebLink
SAN J OACII[Am GOL IN iY ENVIRONMIFN T AI-. C`CEAI ..I FI DEPARTMENT <br /> � FRVICE �3FR. VEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail �t'C �r C ��1/ D � <br /> OWNER / OPERATOR <br /> Quik Stop Markets CHECK If BILLING ADDRESS <br /> FACILITY NAME Quik Stop #76 <br /> SITE ADDRESS 1030 S . Olive Ave95215 <br /> Stockton <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( if Different from Site 3Add Address) W. Thrid Street <br /> O <br /> Street Number Street Name <br /> CITY Cincinnati ST61 Zip 45202 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209 464 - 1038 Site <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors ( 2091461 -6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr 209) (209 ) 461 -6342 <br /> CITY Stockton STATE CA zip 95205 <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 /Iication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , Standards, TATE a d FEDERAL laws. ,j <br /> APPLICANT' S SIGNATURE : (,7 w / /C,X, _ DATE : 2/ 15/2022 <br /> PROPERTY f BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Office 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 provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : rr <br /> — 1'7t. r OcIU�7 C'.4,7 / g' ' ^Iy T <br /> COMMENTS : CA <br /> 84 /V jo <br /> H�gcT�R0N CC iN <br /> � /� > D �N QTY <br /> ACCEPTED BY : / / L EMPLOYEE M DATE : //0 <br /> ASSIGNED TO : EMPLOYEE M DATE : �I7� <br /> Date Service Complete dalreadycompleted) : SERVICECODE : nf2l'� PIE�: 7� <br /> Fee Amount : Amount Paid �5�� � � Payment Date 211,y Zi <br /> Payment Type V� S� Invoice # Check # 1 g9 � 2 Rece ved By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />