Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE4 . REQUEST <br /> Gas Station Q�( , S� Kaal�u � <br /> OWNER / OPERATOR Amba Rai <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Stockton 76 <br /> SITE <br /> 866ADDRESS 8606 Thornton Road Stockton 94566 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> same <br /> Street Number Street Naive <br /> CITY STATE Zip <br /> PHONE #1 Exi , APN # LAND USE APPLICATION # <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> f ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REaUESTOR Matt Thomas <br /> CHECK If BILLING ADDRESS D <br /> BUSINESS NAME CGRS , Inc . PHONE # ExT . <br /> 916 991 - 1100 <br /> f IGME or MAILING ADDRESS FAX # <br /> 5444 Dry Creek Road ( ) <br /> CITY Sacramento STATE CA ZIP 95838 <br /> BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator or authorized agent of same• <br /> acknowledge that all sitz: and 'or project specific ENVIRONNII - NFAl _ HEAT TII Di : I3ARTMFN1 hourly charges associated with giiisproject <br /> or activi !2 <br /> ty will be billed to me car my business as identified on this Form . pa <br /> 1 also certify that l have prepared this application and that the work to be perforated will be done in accordance with alljg . <br /> ia® <br /> C r )1 ' N I' 1' (.b •dinunc'c (" nc% .� , .ti'lrrndcrrdi•, S����I A1111 rI: and FFt ) I RAL laws , t��B <br /> APPLICANT 'S SIGNATURE : DATe : <br /> 6 215/19 SANS 2019 <br /> r <br /> PROPEORTI / Bt 'SINESS ONI-NER ® OPERATOR \ GER ❑ OTHER AUTHORIZED AGIIII ® y�It �lRON N CO6741O <br /> if Al'P1.1< '. L\' T is vol the 1311. 1. 1.\ (; P;IRT) , praof' o/ arrthorizatirnl to sign is required Title ARptij <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , the owner or operator of the property located at he <br /> above site address, hereby authorize the release of anv and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOA ()trrt COUNTY ENVIRONMENTAL HI-AI Tti DFPARTNIFNT as soon as it is available and at the same time it is <br /> provided : o me or my representative .COMMENTS: E <br /> TYPE OF SERVICE REQUESTED : E W IN=-= MOWN r <br /> COMMENTS: <br /> Install new OPW spill buckets and OPW 71 SOT testable overfill valves FEB 1 12019 <br /> ENVIRONMENTAL HEALT <br /> _ DEPARTMENT <br /> ACCEPTED BY : -� ^ EMPLOYEE # : qwl DATE : Z ii I� <br /> ASSIGNED TO : EMPLOYEE # : Ob I DATE : 9 <br /> i i <br /> Date Service Completed ( if already completed ) : SERvice COD e: P / E : OQp <br /> 7Fe:e:Amount. Amount Paid � � Payment Date � <br /> Payment TypeInvoiceInvoice #1 Ch k 40/ Received By : <br /> EHD 483 02-025 <br /> REVISED 11 /17/2003 SR FORM ( Golden Rod ) <br />