Laserfiche WebLink
r SAN JOAQUIAIUNTY ENVIRONMENTAL HEALTH #ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER i OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME US Gasoline <br /> SITEADDRESS 749 E MLK (Formerly Charter Way) Sto�Cit <br /> 95206 <br /> Street Number Direction Street Name ZiD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA LIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> ( 209 ) 465-8979 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR 1 SERVICE REQUESTOR �pI <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS <br /> PHONE# EXT. <br /> BUSINESS NAME HMC - Henderson Maintenance Company 209 467-7573 <br /> HOME or MAILING ADDRESS FAC# <br /> P© Box 31325 ( 209 1465-4988 <br /> CITYStockton STATE CA ZIP 95213 <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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN rY Ordinance Codes,Standards,STATE and <br /> �FEDERAL laws. <br /> APPLICANT'S SIGNATURE: L� . _r DATE: `5-.2 7-1 <br /> PROPERTY IBUSIrtiF;55OW'VERD OPERATOR/MANAGER ® OTHER AUTHORIZED AGENT® <br /> COntraCtOr <br /> If APPLICAW 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 ali 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: '� r` PAYMENT' <br /> COMMENTS: Replace 89 annular space sensor, MAY L 7 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMAL <br /> HEALTH D PART-MENT <br /> .01 <br /> ACCEPTED BY: t EMPLOYEE#: 'DATE: <br /> ASSIGNED To: EMPLOYEE#; DATE: <br /> Date Service Complete (if already completed): $EFVICE CODE: P l E: �� <br /> Fee Amount: Amount Paid �? �. (� Payment Date S <br /> Payment Type Invoice# Check# jG9 LlReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />