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COMPLIANCE INFO_2008-2018
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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2300 - Underground Storage Tank Program
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PR0516354
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COMPLIANCE INFO_2008-2018
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Last modified
4/7/2021 2:01:45 PM
Creation date
6/3/2020 10:00:32 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2008-2018
RECORD_ID
PR0516354
PE
2361
FACILITY_ID
FA0012437
FACILITY_NAME
CHEVRON 352324
STREET_NUMBER
3304
Direction
W
STREET_NAME
HAMMER
STREET_TYPE
LN
City
STOCKTON
Zip
95219
APN
07120013
CURRENT_STATUS
01
SITE_LOCATION
3304 W HAMMER LN
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0516354_3304 W HAMMER_2008-2018.tif
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EHD - Public
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SAN JOAQUI vl'C:OUNTY ENVIRONMENTAL HEALTH DVARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQU ST# <br /> ccs 15�utio� C�(ji V-5-7 ( CyJ- 0�� <br /> OWNER/OPERATOR <br /> Eae ` 4(( I o "5rrtl(?n fic CHECK If BILLING ADDRESS <br /> ' FACILITY NAME <br /> SITE ADDRESS <br /> 330� W / I(AYvin�et'' lul?P <br /> 1 <br /> 1 Street Number Direction Street Name Ci Zi Code <br /> HOME or CLING ADDRESS III Different fropt Site Address) <br /> O -J �Gp �� Street Number Street Name <br /> l;lE Z <br /> 5uyi mar l//'T`n- �yo. <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> V60) 759 -462 0 '7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> yea <br /> SI' � � CHECK If BILLING ADDRESSBUSINESS NAME 1 / III L PHONE# EXT. <br /> �CCff c� /�G{1-� . u SP�v/lP ��c. 6` 7517 Z'Ig <br /> HOME or Ma�� A�DRESS FAX# <br /> %% VA 3e//- <br /> CITY J5an I' a f vo STATE 00 2 ZIP <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 /> 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: DATE: <br /> ROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER I OTHER AUTHORIZED AGENT ❑ U/l(° �j PS�G1fy1� <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessor t information <br /> t0 the SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as It IS available and at the Same time It IS pr /OCI]le Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: V) <br /> COMMENTS: <br /> Q O 01�Y)-e� I/ gRO018N/?ONCti47jyDNT <br /> 7-y <br /> MRNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ V / <br /> ASSIGNED TO: EMPLOYEE#: DATE: "-1 O_ � X <br /> Date Service Completed (if already complete4. SERVICE CODE: I PIE: <br /> Fee Amount: Amount Paid 0 Payment Date 7� Z <br /> Payment Type Invoice# Check# /� Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />
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