COMPLIANCE INFO_1987-2002 - Laserfiche WebLink

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Wo #106'706 . SERVICE REQUEST Type of Business or Property Gasoline Comments: Facility ID# __7 Service Request # Z ?3.3 Retail - C Store 7 ,Sgc Q, Owner / Operator Billing Party ❑ Facility name: Mprel for lens #7 V site address direction "�LTN! street name Contractors Signature: Approved by:JEmployee#:51 1t Wa t eafwl11116 Mid mployee#: S Date: Assigned to: 3 Cl Date: vhw:y, CIL 96.176 Date Service Completed (if already completed): Service Code: P / E: 2 < Fee Amount: iC'7_ CX) typesuite# Amount Paid: a 7oc, Payment Date: Mailing Address (if different form site address) j Payment Type ✓ Invoice # More for Less I Received By: Ylel 1-411 3336 Bradshaw Road - Suite 280 Sacramento, CA 95827 916-369-9740 916-369-3775 (fax) Phone #1 O Fact. APN# Land Use Application # Phone #2 916-369-9740 Ext. BOS District Location Codes CONTRACTOR / SERVICE REQUESTOR Requestor: Linda Steiger Billing Party ■ Business Name Phone # Sacramento Equipment Maintenance Company, Inc. ( 916 ) 925-2716 Mailing Address Fax # 2533 Connie Drive (916)925-2816 Sacramento, CA 95815 BILLING ACKNOWLEDGMENT: I u rsigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific Puauc HEALTH SERVIcEs ENVIRONMENTAL HEALTH 1 s1oN h uriy 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 pplicat' rr and at work to be perfor ed will be done in accordance with all SAN JOAQUIN COUNTY Ordvrance Codes, Standards, STATE and FEDERAL laws. 10 IQ Applicant Signature: , Date: Property / Business Operator / Manager Other Authorized Agent Linda Steiger - President If Applicant is not the Billing PartV, proof of authorization to sign is required T/tle 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 JOAauw COUNTY Puauc HEALTH ENVIRONMENTAL DIVIs1oN as soon as It is available and at the same time it is provided to me or my representative. Type of Service Requested: Replacement of annular sensor on Mid -Grade (89) tank. Remove water from trench on (87) & (89) Comments: V "�LTN! Inspectors Signature: Contractors Signature: Approved by:JEmployee#:51 mployee#: S Date: Assigned to: 3 Cl Date: Date Service Completed (if already completed): Service Code: P / E: 2 < Fee Amount: iC'7_ CX) Amount Paid: a 7oc, Payment Date: 11: 1 7 j Payment Type ✓ Invoice # Check # 1�6' 9 61 IV I Received By: Ylel 1-411 V:\ county \ san Ioaquin \ env \ forms \ permits \ repairsi