Laserfiche WebLink
MXIV D <br /> SAN JOAQU.__ .'.OUNTY ENVIRONMENTAL HEALTH _PARTMENT O+.rT C 5 top <br /> SERVICE REQUEST ENVIRONME T <br /> Type of Business or Property FACILITY ID# SERVICE RE #T/SER SLTF� <br /> Gas station - �j-� �a S�6c��g 1 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS® <br /> Mr.Angle <br /> FACILITY NAME <br /> SHELL Angles Petroleum <br /> SITE ADDRESS 7700 E Moreland Court Stockton 95212 <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 ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT -7LOCATIION ODE <br /> IO <br /> ( ) - L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Greg Kaiser CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Kaiser Commercial Petroleum 20 887-2639 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 1058 ( ) <br /> CITY Linden STATE CA ZIP 95236 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 FEDE Al-laws. <br /> APPLICANT'S SIGNATURE: UWP <br /> DATE: 10/23/2017 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR A GER ❑ OTHER AUTHORIZED AGENT ® Contractor <br /> If APPLICANT Is not the BILLING PTY,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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Repair UDC 5 &6 Interstitial communication. R� yME <br /> COMMENTS: Oct F� <br /> Install new communication port on dispenser 5 &6 UDC. any <br /> 7;yOFa 44H� <br /> Fv)� <br /> ACCEPTED BY: EMPLOYEE#: DATE: /D I <br /> ASSIGNED TO: / EMPLOYEE#: DATE: d .� l <br /> Date Service Completed (if already co leted): V SERVICE CODE: I PIE: <br /> Fee Amount: 1DI U/, , Amount Paid L � � Payment Date lv — <br /> Payment Type Invoice# Check# Receive/d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />