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COMPLIANCE INFO_1987-2002
Environmental Health - Public
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EHD Program Facility Records by Street Name
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2300 - Underground Storage Tank Program
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PR0231939
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COMPLIANCE INFO_1987-2002
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Last modified
11/14/2023 10:51:15 AM
Creation date
6/3/2020 9:54:59 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
1987-2002
RECORD_ID
PR0231939
PE
2361
FACILITY_ID
FA0002570
FACILITY_NAME
QUIK STOP MARKET #3144
STREET_NUMBER
7272
STREET_NAME
WEST
STREET_TYPE
LN
City
STOCKTON
Zip
95209
APN
094-040-13
CURRENT_STATUS
01
SITE_LOCATION
7272 WEST LN
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0231939_7272 WEST_1987-2002.tif
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EHD - Public
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08/19/2002 12:45 464013 ENVIRONMENTAL HEALTH PAGE 01 <br /> bA.N JOAQUIN COUNTY ENVIRONMENTAL MA1LT FA.ItE;MI''NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID'# SERVICE REQUEST# <br /> OWNER I,OPERATOR CHECK if BILLING ADDRESS❑ <br /> FAcILrrY NAME <br /> '79-7�i_ <br /> SRE ADDRESS <br /> LaneStrom NameZip Codo <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number <br /> CITY STATE ZIP <br /> PHONE#1 TAPN 11 LAND USE APPLICATION# <br /> ca - g812- <br /> HOI E#2 �• $i�O5 LOCATIdN COD1_'.`"' <br /> FI( <br /> ' <br /> CONTRAC'T'OR/ SERVICE R.EQUESTOR <br /> PFQUESTOR CHECK If BILLING ADDRESS❑ <br /> �-rnw-t-a. fle S <br /> B Sr1 1NEss NAME= PTI # %2,Q EXT. <br /> HOME orAILI E S FAX <br /> I ) 'v <br /> CITY ESTATE QIP <br /> BILLING ACXNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,. <br /> acknowledge that all site and/or project specific ENviRONrvtENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to the or my business as identified on this form. <br /> I also certify that I have prepared this application and that the woik to be performed will be done in accordance with all SAN JoAQurN <br /> COUNTY Ordinance Codes,Slandards ATL and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: � <br /> PROPER ry/BusiNeS3 OWNER❑ OPERATOR/MANAGER ❑ Alm AuTnoRrzEn AGENT AA <br /> I \ <br /> 1fAPPLICANT is not the B &,R TY proof of authorization to sign is required Title <br /> AUTIFLM7,ATION TO RELEASE INT- RMATYON:When applicable,T,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 SERvia REQUESTED: <br /> COMMENTS: <br /> -APPROVED ey . ... EMPLQYEE#: ; 2'. DATE: .:."h <br /> 'AS'SIGNED TO.wEMPLOIIEE#: pATE:_;:,r, ,;�,• �': v.:. <br /> pate Service'Compiet (If aiready comp'letbd): <br /> I`ee Amount: '� Amount Paid :a Payment Data <br /> -77 <br /> ��7 <br /> Payment TyInvoice# Check# <br /> pe <br /> EHD 48.01.025 ` SERVICE REQUEST4fORM <br /> REVISED 6-6.02 <br />
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