Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gasoline Dispensing Facility `5'7j- 3L <br /> Charter Way Holdings, LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Charter Way 76 <br /> SITE ADDRESS FYZsilo <br /> 1720 S.Zmwse-Ave. Stockton F952C6 <br /> Street Number Direction Street Name Cit i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. API# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <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 /> PO Box 1025 ( 916 )373-1182 <br /> CITY STATE ZIP 95691 <br /> West Sacramento CA <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: ��M�IM DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 Construction Manager <br /> If APPLICANT is not the BILLING PARTY./hoof 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 t)me It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: / e GO <br /> COMMENTS: ` �O <br /> �sAN APR?620 <br /> t`yFgc� RONIN oU�1 <br /> C <br /> DEpgRNT NTy <br /> ACCEPTED BY: STaC IC2'A/ EMPLOYEE#: DATE: p <br /> ASSIGNED TO: 0 // / / /6;e7 C/f — 0 EMPLOYEE#: DATE: 2 �jl <br /> Date Service Completed (if already com/tpllettedd)L:/ SERVICE CODE: O / PIE: C--�-/f—j ice, <br /> Fee Amount: �30( 0 Amount Pa' OL Payment Date <br /> C��J <br /> e <br /> Payment Type Invoice# Check# S g Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />