Laserfiche WebLink
SAN JOAQUI*COUNTY ENVIRONMENTAL HEALTH ITEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDF <br /> OWNER/OPERATOR <br /> CHECK if BILL G R <br /> FACILITY NAME National Petroleum <br /> SITE ADDRESS 3440 1 E Main St Stockton 95205 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1 209 ) 463-7716 <br /> PHONE#2 EXT• BIDS DISTRICT LOCATION CODE <br /> ( ) O <br /> CONTRACTOR/ SERVICE REQUES,TIOR <br /> REQUESTOR Carl Wayne Henderson -T6J &2 3 CHECK If BILLING ADDRESS <br /> BUSINESS NAME Service Station Testing-SST INC/CSLB 962520 PHONE# ExT• <br /> 209 465-5577 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31465 (209 ) 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <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: C .–� '4—'e DATE: 9/29/15 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT® President <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. p <br /> TYPE OF SERVICE REQUESTED: TANK RETROFIT <br /> Redilveft <br /> COMMENTS: ft S`P•2 9 <br /> 2015 <br /> Replaced 420 sensor at L-5(87 tank annular space). S JOAQUIIV <br /> IE DER A N7Y <br /> R&MIN <br /> ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: C?_ <br /> ASSIGNED TO: V V EMPLOYEE#: DATE: -/-2q- <br /> Date Service Completed (if already completed): 9/28/15 SERVICE CODE: 'Cq /P 1 E: I Z' <br /> Fee Amount: '` Amount Pa 6 6.6D Payment/Date 72%/—/ <br /> Payment Type Invoice# Check# 63/'5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />