COMPLIANCE INFO_2008-2009 - Laserfiche WebLink

Home Browse Search

9255517888 Line 159 p.m. 04-20-2009 3/13 O SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILISERVICE REQUEST # SERVICE STATIONa.CL023L BUSINESS NAME Gettler Ryan Inc. OWNER i OPERATOR PHONE # 925 BP West Coast Products LLC CHECK if BILLING ADDRESS FACILITY NAME ARCO 2130 FAX# ( 925 ) SITE ADDRESS 7906 N EL DORADO ST ZIP 94568 STOCKTON 95210 Street Number Direction Street Name -CItV Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court, Suite J Street Numb street Name CITY STATE ZIP Dublin CA 94568 PH0NE#1 EXT. APN # LAND USE APPLICATION# ( 925 ) 551-7555 PHONER EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR LIDDY MCKENZIE R EC E I V E D CHECK if BILLING ADDRESS 0 BUSINESS NAME Gettler Ryan Inc. ACCEPTED BY: PHONE # 925 551-7555 EXT HOME or MAILING ADDRESS 6747 6747 Sierra Court, Suite J FAX# ( 925 ) 551-7888 CIN Dublin STATE CA ZIP 94568 BILLING ACKNOWLEDGEMENT: I, 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 laws. APPLICANT'S SIGNATURE: �Qi A DATE: d PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 1Z AjentfoeOwner If APPmcAivT 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. TYPE OF SERVICE REQUESTED: UST RETROFIT R EC E I V E D COMMENTS: REPLACE 1-2 DISPENSER PAN SENSOR FOR DISPENSER 3/4 APR 2 0 2009 SAN JOAQUIN COUNT`! ENVIRONMENTAL t4EALTH DEPARTMENT ACCEPTED BY: EMPLOYEE DATE: ASSIGNED TO: EMPLOYEE MW2 6 DATE: Date Service Completed (if already completed): SERVICE CODE: J%' PIE: Fee Amount: � Amount Paid vs — Paymen Date 0 Payment Type Invoice # 61teCfF- a 3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003