Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH uEPARTMENT <br /> SERVICE REQUEST <br /> SERVICE R <br /> Type of Business or Property FACILITY ID# EQU7EST# <br /> GDF �Cj n <br /> OWNER/OPERATOR gill Norb <br /> Y CHECK If BILLING ADDRESS <br /> FACILITY NAME Waterloo Shell <br /> --7— <br /> SITEADDRESS 4315 Waterloo Rd Stockton 95205 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 931-3674 6k7 / OCJ -3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS <br /> BUSINESS NAME HMC- Henderson Maintenance Company PHONE#t EXT. <br /> 209 467-7573 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31325 (209 ) 465-4988 <br /> CITY Stockton STATE CA ZIP 95213 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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: L„„ ""� DATE: 5/7/09 <br /> PROPERTY/BUSINESS OWNER 1:1 1 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> if 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: Tank Retrofit LA-S—r 46-na-'7 t-tT- <br /> COMMENTS: Replaced 91 STP sump sensor found to be defective during Annual Monitor Certification. Re �d1 WT <br /> sensor with 323 (TAMPER RESISTANT) sensor and confirmed operability with Inspector on s CEIVED <br /> MAY - 7 2009 <br /> EJOAQUIN COUN <br /> NVIRONMENTALTM <br /> ACCEPTED BY: O l v ( ,/J AEMPLOYEE#: A T 3 2-( DATE: :id-7 <br /> ` )C <br /> ASSIGNED TO: /1'C �i�SEMPLOYEE#: VG f(i 3�, DATE: s• -71/ <br /> Date Service Completed (if already completed): 5/6/09 SERVICE CODE: / P/E: [ �� <br /> Fee Amount: 3 1 S• O v Amount Paid 3 1 5 — Payment Date S 17 Ib <br /> Payment Type Invoice# Check# 1 3 $ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />