COMPLIANCE INFO 2008 - 2015 - Laserfiche WebLink

Home Browse Search

SAN JOAQUI 'OUNTY ENVIRONMENTAL HEALT► ZPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SERVICE REQUEST # GDF 3 G� O PHONE # EXT. 209 467-7573 :Ce/( E / r OWNER/ OPERATOR FAx # ( 209) 465-4988 CITY Stockton EMPLOYEE M D Z Lawrence ASSIGNED TO: �/�% C) �j 6 CHECK if BILLING ADDRESS ❑ FACILITY NAME Arco - Stockton Wilson 130 Date Service Completed (if already completed): 10/6/09 SERVICE CODE: j SITE ADDRESS 130 S I I Wilson Way Payment Date 10/7/6q Stockton Invoice # 95205 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (if Different from Site Address) Street Number Street Name CITY STATE CA ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209 ) 466-6633 /S5= OAU — G4 PHONE #2 EXT. ( )171 BOS DISTRICT LOCATION CODE 1 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS BUSINESS NAME HMC -Henderson Maintenance Company (replacement for Red Jacket CPT). PHONE # EXT. 209 467-7573 HOME or MAILING ADDRESS PO Box 31325 FAx # ( 209) 465-4988 CITY Stockton EMPLOYEE M D Z STATE CA ZIP 95213 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: Ce--'� t-- _ L/ DATE: / " 7 - c 7 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor /f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ct-s %- 23- %720 F l% TYPE OF SERVICE REQUESTED: TANK RETROFIT COMMENTS: PAYMENT Repaired existing Red Jacket Variable Speed Flow Controller (VSFC) installation at 87 lVRM& RQ (replacement for Red Jacket CPT). OCT 0 7 2009 Certify VSFC, PLLD operability and POSITIVE SHUTDOWN. SAN JOAQUIN COUNTY ENHFALVIRONMENTAL DEPMAR. MENT ACCEPTED BY: L U E t EMPLOYEE M D Z DATE: O ASSIGNED TO: �/�% C) �j 6 EMPLOYEE #: �� DATE: Date Service Completed (if already completed): 10/6/09 SERVICE CODE: j P I E: 3O Fee Amount: 4 S^ co Amount Paid � s - Payment Date 10/7/6q Payment Type Invoice # Check # 1 C) 3 ` g Received By: NZS EHD 48-02-025 REVISED 11/17/2003 (� %_ ; l/py SR FORM (Go!