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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station <br /> OWNER/OPERATOR <br /> West Valley Chevron CHECK if BILLING ADDRESS <br /> FACILITY NAME West Valley Chevron <br /> SITE ADDRESS 2615 West Grantline Road Tracy 95376 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address)Same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 )836-3464 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (408)636-6651 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Randy Brown CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE# EXT. <br /> Gettler-Ryan Inc. 925-551-7555 <br /> HOME Or MAILING ADDRESS FAx# <br /> 6747 Sierra Court Suite J ( )925-551-7888 <br /> CITY Dublin STATE Ca zlP 94568 <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 /> 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 Coder,Standards,ST d FE : L laws. <br /> APPLICANT'S SIGNATURE: DATE: April, 19, 2012 <br /> PROPERTY/BUSINESS OWN ER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT O,Service Manager <br /> IfAPPL/CANT 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: Permit Approval <br /> COMMENTS: <br /> Replace failing Product and conduit penetration fittings on 87, 91 & Diesel piping sumps. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: $375.00 Amount Paid $375.00 Payment Date April 19,2012 <br /> Payment Type Credit Card 7 Invoice# Check# Received By: <br /> Confirmation #A38169 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />