Laserfiche WebLink
SAN J(-,'kk, iN COUNTY ENVIRONMENTAL HEALTH .oEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -F <br /> Gas Station 3�Ss ( �DC Gj(�2 <br /> OWNER/OPERATOR J J `d 7 <br /> Tesoro Refining and Mmarketing CHECK If BILLING ADORESM <br /> FACILITY NAME USA Gas 9+(eg( S 3 <br /> SITE ADDRESS 2448 W Kettleman Ln <br /> Lodi 95242 <br /> Stmt Number n n a city <br /> Zip c9do <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3450 S 344th Way <br /> Strut Number tral NaMe <br /> CITY Auburn STATE WA ZIP 98001 <br /> PHONE#1 EXT. APN I LAND USE APPLICATION M <br /> ( 253 896-8700 <br /> PHONE 82 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RECIUESTOR <br /> Marty Weithman CHECK H BILLING ADDRESS <br /> BUSINESS NAME Able Maintenance, Inc PHONE# EXT. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS FAx# <br /> 680 Quinn Ave <br /> (408 )213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �' j;Q�t`LC, �' ')�!� {I t tiL�.ti�; DATE: '7 4. 'h <br /> tcj <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTNER AUTHORIZED AGENT❑ Compliance Officer <br /> 1f APPLICANT is not the BILLING PARTY,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: inspection t15T O EE`• -D <br /> COMMENTS: <br /> pU� 0 5 �00� <br /> 5AENVOIR0 � <br /> NMEWAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 10 60 <br /> EMPLOYEE#: DATE: s U <br /> ASSIGNED TO: 5 EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 36K <br /> Fee Amount: Einvc0ce <br /> Amount Paid � Payment DatePayment Type # Check# 24 Received By: — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />