COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

9255517888 Line? 53:43 09-04-2012 3/13 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Pqy ERVICE REQUEST # SERVICE STATION 6v BUSINESS NAMEPHONE Gettter Ryan Inc. goo65—L OWNER / OPERATOR EXT• ASSIGNED TO: West Coast Products LLC 925 HECK if BILLING ADDRESS ADDRESS[] FACILITY WE ARCO 2093 SERVICE CODE: FAX # SITE ADDRESS 3425 6747 Sierra Court, Suite J TRACY BLVD ( 925 ) TRACY Crnr Dublin 95376 Street Number Direction Street Name Received By: (� Ci HOME or MAILING ADDRESS (if Different from Site Address) 6747 Sierra Court, Suite J Street Number Street Name CITY STATE ZIP Dublin CA 94568 PHONE#1 EXT. APN# LAND USE APPLICATION# ( 925 ) 551-7555 PHONE#2 EXT, SOS DISTRICT ON CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Pqy LIDDYMCKENZIE CHECK if BILLING ADDRESS© BUSINESS NAMEPHONE Gettter Ryan Inc. # EXT• ASSIGNED TO: 925 551-7555 HOME or MAILING ADDRESS SERVICE CODE: FAX # PIE:; o 6747 Sierra Court, Suite J Amount Paid ( 925 ) 551-7888 Crnr Dublin STATE CA zip 94568 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that thew01to be rmed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL I s. �, t APPLICANT'S SIGNATURE: G DATE: �-�"' 1 PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGE OTHER AUTHORIZED AGENT q Agent for Owner If APPLICANT is not the BILLING PRIiTY proof of authorization to sign is required Time AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: UST RETROFIT Pqy COMMENTS: REPLACE SENSOR 323 ON 87 FILL SUMP. SEP 0 �t;lV JOAQUi yEANTNRON PA ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (If already completed): SERVICE CODE: PIE:; o Fee Amount: ' Amount Paid �?J�S Paymen Date 9 �q-� I Z Payment Type �► r Invoice # Check # Received By: (� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 ENT /V86 2012 Fk COUNTY