Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Fuel dispensing station �Amm� 3 �-'� S � (� O grj (p <br /> OWNER / OPERATOR ,Q <br /> 5 U /1 WIA �6 / ) CHECK If BILLING ADDRESS <br /> FACILITY NAME !!! / / �f� (/J V <br /> Lodi Chevron <br /> SITE ADDRESS 601 E Kettleman Lane Lodi PA <br /> Street Number Direction I Street Name Cit N" • N r <br /> HOME or MAILING ADDRESS (If Different from Site Address) E1) <br /> Street Number Street Name <br /> CITY STATE ZIP 024 <br /> SAN 77 <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # ul <br /> NE NVIRONIl7 c VNTy <br /> ALTH DEPART ENT <br /> ( ) <br /> PHONE #T Exr. BOS DISTRICT LOCATION CODE <br /> in <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> BZ Maintenance 916 371 - 2380 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 933 ( ) <br /> CITY W Sacramento STATE CA ZIP 95691 <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 t t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards , STATE a R laws . <br /> APPLICANT'S SIGNATURE : DATE : <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to Sigh 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : S T �} I <br /> COMMENTS: <br /> Remove currently installed straight drop tubes from all tanks . Measure and cut drop tubes with <br /> flappers according to tank charts . Test with EMD . Install drop tubes with flappers into tanks . <br /> ACCEPTED BY: �j/ 0 � � �> EMPLOYEE #: DATE: 3 I q� 2 <br /> ASSIGNED TO : Vclty ) Lee EMPLOYEE # : DATE : / I 29[ <br /> Date Service Completed ( if already completed ) : SERVICE CODE : „ . ;'r: PIE : 2 :D ( D <br /> Fee Amount: pry- , ; ° Amount Paid �� Payment Date 3 2 2 <br /> Payment Type ('�� �-� ( Invoice # Check # 783 / Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />