Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station t-(� ���p r,06 e&tn 1 <br /> OWNER/OPERATOR <br /> Harkamal'it Cha er CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Sinclair DBA 1)Wayz Food and Liquor and 2)Wayz Gas and Liquor <br /> SITE ADDRESS Lathrop 95330 <br /> 16470 Cambridge Dr <br /> Street Number Direction Street Name Cit , Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 810 Garland Way <br /> Street Number Street Name <br /> CITY STATE zip <br /> Brentwood 94513 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (510 ) 509-0330 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Harkamaljit Chagger CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Sinclair DBA 1)VVayz Food and Liquor and 2)Wayz Gas and Liquor 510 509-0330 <br /> HOME Or MAILING ADDRESS FAX# <br /> 810 Garland Way ( ) <br /> CITY STATE ZIP <br /> Brentwood CA 94513 <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: 2/22/23 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 <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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Q <br /> EB 2COMMENTS: <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ` \� EMPLOYEE#: DATE: 2--'23- 23 <br /> ASSIGNED TO: `/ \,. C7\ EMPLOYEE#: DATE: 2 — 2 <br /> Date Service Completed (if already Completed): SERVICE CODE: I P/E: 1 <br /> Fee Amount: i Is b Amount Paid 5 b Payment Date 7 — 2-2_ -Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />