Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Proposed Truck Stop <br /> OWNER/OPERATOR <br /> Apna Petroleum Corp. /Charanjit Jutla CHECK if BILLING ADDRESS X❑ <br /> FACILITY NAME Ahern Truck Stop <br /> SITE ADDRESS 29700 1 S. Ahern Rd. Tracy 95304 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3940 N. Tracy Blvd. <br /> Street Number Street Name <br /> CITY Tracy STATE CA Zip 95304 <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> ( 209) 832-5006 255-020-14 PA-1600049 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAx# <br /> 407 W. Oak St. ( ) <br /> clTM Lodi STATE CA Z'P 95240 <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 FED L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® C o i,(--m"11— <br /> If APPLICANT 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 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: Review Soil Suitability/Nitrate Loading StudyrTkz <br /> piq <br /> COMMENTS: CC/�A(?` <br /> sqN MAR 1 B ?0 <br /> /yzi TSR NDN CO 20 <br /> O FN NT <br /> ACCEPTED BY: }� � EMPLOYEE#: DATE: MEjVT <br /> ASSIGNED TO: \ ` EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: '�� P I E: <br /> Fee Amount: Amount Pai �bg ��D Payment Date 3 /,F/�-'L9 <br /> Payment Type Invoice# Check# f� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />