COMPLIANCE INFO_2011-2018 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station 6-6,79 .5k 00 OWNER / OPERATOR 1 P CHECK tf 0 --R9 0S"bit-- BILUNG ADDRE FACILITY NAME Harlan Shell EXT. SITE ADDRESS 16500 S Harlan Rd, Lath r p CA 95330 213-6038 HOME or MAILING ADDRESS 680 Quinn Ave F21. roNumber Payment Date Payment Type Stmt Name city C.W. HOME or MAILING ADDRESS (if Different from Site Address) STATE CA ZIP 95112 Street Number stroet Name CITY STATE ZIP PHONE 91 ExT. ( 1 APN E LAND USE APPLICATION # PHm#2 Ext. EIOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTflR Marty Weithman PAYMENT COMMENTS: Nov 14 2013 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: i s l CHECK ifSILLINGADDRESSM BUSINESS NAME Service Station Systems, Inc. ASSIGNED TO: PHONE# EXT. Date Service Completed (H already completed): 408 213-6038 HOME or MAILING ADDRESS 680 Quinn Ave Amount Paid FAX# Payment Date Payment Type Invoice # (408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 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 IaWS. APPLICANT'S SIGNATURE:DATE: 11/12/2013 PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENTs0 Compliance Officer IfAPPLICANT 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. TYPE OFSERviCEREQUF : UST inspection PAYMENT COMMENTS: Nov 14 2013 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: i s l EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE #: fd t� L DATE: Date Service Completed (H already completed): SERVICE CODE: l 6 8 P I E: 023 og Fee Amount: Amount Paid 7 — Payment Date Payment Type Invoice # Check # 2 t s- Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 1111712003