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SAN JOAQU*ouNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fueling Station E &44� 52oo&4¢73 <br /> OWNER/OPERATOR PG&E CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME PG&E Service Center <br /> SITE ADDRESS 4040 West West Lane Stockton 95204 <br /> Street Number Direction Street Name Gil Z'P Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)3401 Crow Canyon Road <br /> Street Number Street Name <br /> CITY San Ramon STATE Ca. x'$563 <br /> PHONE#1 EaT. APJ# LAND USE APPLICATION# <br /> (925 )415-6330 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Randy Brown CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Eu. <br /> Gettler-Ryan Inc. 925-551-7555 <br /> HOME or MAILING ADDRESS FAX III <br /> 6747 Sierra Court Suite J ( )925-551-7888 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I 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,ST EDERAL laws. <br /> APPLICANT'S StGNATU DATE: February 28, 2012 <br /> v <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[3 Service Manager <br /> /fAPPL/CANT is not the BILLING PAKTP proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: Permit Approval pgyMENT <br /> COMMENTS: R <br /> hu <br /> FES 2 9 2012 <br /> Replace faulty sensor in 87 fill sump. A�Ro++Y�� <br /> HEALTH DEPARTM� <br /> ACCEPTED BY: t--PUZ EMPLOYEE#: G'o DATE: 2( /Z <br /> ASSIGNED TO: b-A /d al� EMPLOYEE#: / 'JG DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /R d PIE: Z 3 b F <br /> Fee Amount: $375.00 1 Amount Paid $375.00 Payment Date February 28,2012 <br /> Payment Type Credit Card Invoice# Check# Received By: <br /> Confirmation #A53958 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />