Laserfiche WebLink
SAN JOAN COUNTY ENVIRONMENTAL HEALTREPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station <br />0 <br />OWNER / OPERATOR <br />HOME orMAILiNGADDRESS 680 Quinn Ave <br />MAR <br />Tesoro Corporation <br />) 213-6026 <br />CHECKifBILUNGADDRESS❑ <br />FACILITY NAME Shell(Tesoro) <br />ZIP 95112 <br />SAN EN� ONME BENT <br />SITE ADDRESS 35 N. Cherokee Lane, Lod CA 95240 <br />I <br />HEAI IN OF <br />StmANwnber olrfttion <br />SlrW Name <br />EMPLOYEE #: Z <br />HOME or MAILING ADDRESS (if Different from SRO Address) <br />3450 S. 344th Way <br />EMPLOYEE #: r q - Z <br />? <br />Street NumberStreet <br />Name <br />CITY Auburn <br />STATE WA <br />Zip 98001 <br />PHONE #1 Exr. <br />APN * <br />LAND USE APPLICATION # <br />( 2538b6-8700 <br />Payment Date <br />? ) <br />Payment Type f <br />PHONE 02 En. <br />( 1 <br />SOS DISTRICT <br />LocAT1oN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RECIUESTOR Marty Weithman <br />CHECKIfS&LINGADDRESS <br />BuslNEss NAME Able Maintenance, Inc <br />PHONE# <br />408 <br />EXT. <br />213-6038 <br />HOME orMAILiNGADDRESS 680 Quinn Ave <br />MAR <br />FAX# <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNQWW E GEMENT: 1, 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 l 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( o,, -, ) - 7V,(, d. DATE: 2/28/2011 <br />PROPERTY /BUsmESsOWNERM OPERATOR/ MANAGER ❑ OTHERA11THORIZED AGENT E) Compliance Officer <br />JfAPPLICANT is not the BILLJNGPARTY proof of authorization to sign is required Tittle <br />AUTHORIZATION TO RELEASE INFORMATJON: 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: UST inspection <br />pAYM <br />COMMENTS: <br />MAR <br />COUNTY <br />SAN EN� ONME BENT <br />HEAI IN OF <br />ACCEPTED BY: UL t E <br />EMPLOYEE #: Z <br />DATE: 312411 Z 1/ <br />ASSIGNED To: CA CAP 1-T <br />EMPLOYEE #: r q - Z <br />? <br />DATE: 3 <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( <br />PIE: <br />Fee Amount: qf-3 6&, CA) <br />Amount Paid <br />11 3L, L , p 0 <br />Payment Date <br />? ) <br />Payment Type f <br />Invoice # <br />Check # --1,qF9 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />