Laserfiche WebLink
SAN JOAQ–.,r COUNTY ENVIRONMENTAL HEALTH —,;PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />gas station <br />-7 7 1 ]- & <br />OWNER /OPERATOR <br />CHECKIIIBILLINGADDRESSM <br />Chevron USA <br />CHECK If BILLINGADDRESS <br />FACILITY NAME <br />E-". <br />Chevron <br />SITE ADDRESS 10858 Trinity Prkway, <br />St <br />ckton CA 95219 <br />FAx <br />ENVIPOAR',-F, 1 AL <br />Street Number <br />Direction <br />HEAT 'H ULNAHTML=NT <br />n Name <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />Street Number <br />Stroet Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN * <br />LAND USE APPLICATION « <br />PHONE#2 En. <br />Amount Paid <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />'yy'rr��ii <br />Marty Weithman <br />CHECKIIIBILLINGADDRESSM <br />BUSINESS NAME <br />PHONE# <br />E-". <br />Able Maintenance, Inc <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />FAx <br />ENVIPOAR',-F, 1 AL <br />680 Quinn Ave <br />HEAT 'H ULNAHTML=NT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNOWLEDGEMENT: 1, 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 1 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: v }lV,E� L(_AI L-1 DATE: <br />PROPERTY/ BUSINESS OWNERO OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT O <br />IJAPPLICANT is not the BILI ING PARTY, proof of authorization to sign is required <br />5/10/2012 <br />Compliace Officer <br />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. <br />TYPE OF SERVICE REQUESTED: UST inspection <br />PAYMENT <br />COMMENTS: <br />RECEIVED <br />MAY 14 <br />SAN JOAQUIN COUNTY <br />ENVIPOAR',-F, 1 AL <br />HEAT 'H ULNAHTML=NT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: S <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P/ E: <br />Fee Amount: <br />Amount Paid <br />2�"�1t"` <br />Payment Date L' <br />Payment Type v <br />Invoice # <br />Check <br />Received By: <br />EHD 48.02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />