Laserfiche WebLink
SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTHtEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station <br />11 <br />3 (off <br />sr -01L1 (�' -4-1� `7 <br />OWNER /OPERATOR <br />STATE Ca zIP 94568 <br />BP West Coast Products LLC <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Arco 2093 <br />EMPLOYEE MG� �� j 3 <br />DATE: <br />SITE ADDRESS 3425 <br />Tracy Blvd <br />Tracy <br />DATE: <br />lE:23 <br />95376 <br />Street Number <br />Direction <br />Stre <br />Name <br />Ci <br />$375.00 <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 4 <br />Invoice # <br />Centerpoint Drive <br />Check # <br />Street Number <br />Street Name <br />CITY La Palma <br />STATE Ca. ZIP 90623 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 530)621-0770 <br />PHONE R EXT. <br />( I <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Randy Brown <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Gettler-Ryan Inc. <br />RECEIVE D <br />PHONE # ExT' <br />925-551-7555 <br />HOME or MAILING ADDRESS <br />6747 Sierra Court Suite J <br />Replace failing 87-2 & 91 fill spill buckets. <br />FAX # <br />( )925-551-7888 <br />CITY Dublin <br />STATE Ca zIP 94568 <br />BILLING ACKNOWLEDGEMENT: I, 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 Codes, Standards, STAT EDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: April, 16, 2012 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 1 Service Manager <br />f f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 />RECEIVE D <br />APR 18 2012 <br />Replace failing 87-2 & 91 fill spill buckets. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: In q ri, I J <br />V ` r ire <br />EMPLOYEE MG� �� j 3 <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: (� <br />DATE: <br />lE:23 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 1 <br />P 1 Q <br />Fee Amount: $375.00 <br />Amount Paid <br />$375.00 <br />Payment Date April 16,2012 <br />Payment Type Credit Card <br />Invoice # <br />Check # <br />Received By: <br />Confirmation # A57046 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />