COMPLIANCE INFO_2001-2011 - Laserfiche WebLink

Home Browse Search

SAN JOAQ* COUNTY ENVIRONMENTAL HEALTREPARTMENT SERVICE REQUEST Type of Business or Property GDF FACILITYLD # d V 06�-Jq-7 SERVICE REQUEST # OWNER/ OPERATOR Bob Lutz HMC -Henderson Maintenance Company RECEIVED JUN 2 9 2010 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT CHECK if BILLING ADDRESS FACILITY NAME EI Dorado Food Mart ( SHELL ) PO Box 31325 FAX # ( 209 ) 465-4988 SITE ADDRESS 2320 Street Number N I Direction EI Dorado St I Street Name DATE: Stockton city 95209 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number P I E: Street Name CITY 3 STATE CA ZIP PHONE #1 EXT. ( ) APN # Check # ` � LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAME HMC -Henderson Maintenance Company RECEIVED JUN 2 9 2010 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PHONE # EXT. 209 467-7573 HOME or MAILING ADDRESS PO Box 31325 FAX # ( 209 ) 465-4988 CITY Stockton 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 1 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: �� L--. "oA - DATE: 6/29/10 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, I, 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. TYPEOF SERVICE REQUESTED: TANK RETROFIT PAYMENT COMMENTS: Replaced defective sensor 6/28/2010. RECEIVED JUN 2 9 2010 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED B EMPLOYEE #: DATE: 2 /� v ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): 6/28/10 SERVICE CODE: f P I E: Fee Amount: Amount Paid 3 Payment Date O Payment Type ✓ Invoice # I Check # ` � Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003