COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # ERVICE RE STT Gas StationPOO OWNER / OPERATOR CHECK If BILLING ADDRS Anabi Oil FACILITY NAME Shell SITE ADDRESS 2375 W Grant Line Road Tracy 95377 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1450 N . Benson Avenue Street Number Street Name CITY STATE ZIP Upland CA 91786 PHONE #1 EXT, APN # LAND USE APPLICATION # ( 760) 722 - 9002 PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS Scott Willett BUSINESS NAME PHONE # EXT' DiMaggio Maintenance Inc . 760 722 - 9002 HOME or MAILING ADDRESS FAX # 1040 Joshua Way (760) 722 - 9009 CITY Vista STATE CA ZIP BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner t of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTproject 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 th ' JOAQUIN COUNTY Ordinance Codes, Standards, STATE anf' APPLICANT' S SIGNATURE PROPERTY / BUSINESS OWNER ❑ If APPLICANT is no, / AUTHORIZATION TO RELEASE we site address , hereby authorize the on to the SAN JOAQUIN COUNTY ENVIRON \ � or my representative. TYPE OF SERVICE REQUESTED : ? � v GrL COMMENTS: " S n � v l� n C� � ACCEPTED BY: 1 /v _mPLOYEE #: DATE : ASSIGNED TO : L�1 EMPLOYEE # : DATE: fJ ! Date Service Completed (if already completed) :=e — SERVICE CODE : Fee Amount: .� ( d Amount Paid Payment Date Payment Type Invoice # Check # Received By : EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 it