Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station /Convenlance Store X i - 7 3 � eO0 6 , - / <br /> OWNER / OPERATOR BP ARCO WEST COAST PRODUCTS LLC CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> ARCO # 2186 <br /> SITEADDRESS 3212 N CALIFORNIA Stockton 95204 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) pq <br /> P . O . Box 6038 Street Number Street Name ^I / <br /> CITY STATE ZIP � 1 i 'Ay <br /> Artesia CA 90702 <br /> PHONE #1 EXT , APN # LAND USE APPLICATION # <br /> ( 847) 340 -3092 8 <br /> 4 <br /> N �o 203 <br /> PHONE #2 EXT , BOS DISTRICT LOC O C <br /> ( ) pq� 7771 Z�Y <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Merlin Bowen (Agent for Contractor) CHECK If BILLING ADDRESSe <br /> BUSINESS NAME PHONE # EXT , <br /> Gelller•Ryan , Inc. 925 551 . -7555 <br /> HOME or MAILING ADDRESS 6805 Sierra Court , Suite G ;' 5 551 - 7888 <br /> CITY Dublin STATE CA ZIP 94568 <br /> BILLING ACKNOWLEDGEMENT: I , 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 or <br /> activity will be billed to me or my business as identified on this form . <br /> also certify that I 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 : � � 4� DATE : 1 / 18/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT e Permit Tech <br /> If APPLICANT is not the BILLING PARTY proof of authorization to Sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> 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 <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : MANWAY , SPILL BUCKET AND DROP TUBE/OVERFILL VALVE REPLACEMENT <br /> COMMENTS : <br /> ACCEPTED BY: �� C EMPLOYEE # : DATE : <br /> ASSIGNED TO : /� EMPLOYEE # : DATE : I r <br /> Date Service Completed ( if already completed ) : SERVICE CODE : lqf, g PIE : ` <br /> Fee Amount: (.f' Amount Paid 00 Payment Date L3 <br /> Payment Type Invoice # Check # .0q7 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />