Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station 600 ?7 7 7 2 '�3 tZ 001 Z2 Lo <br /> OWNER <br /> oOWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Anabi Oil <br /> FACILITY NAME <br /> Shell <br /> SITE ADDRESS 2375 WGrant Line Road Tracy 95377 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1040 N . Benson Avenue <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Upland CA 91786 <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 760) 722 - 9002 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Scott Willett CHECK If BILLING ADDRESSID <br /> BUSINESS NAME PHONE # ExT. <br /> DiMaggio Maintenance Inc . 760 722 - 9002 <br /> HOME or MAILING ADDRESS FAx # <br /> 2603 Industry Avenue (760 ) 722 - 9009 <br /> CITY Oceanside STATE CA ZIP 92054 <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 or <br /> 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 : DATE : 03/05/2020 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Operations Manager <br /> If 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> 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 <br /> my representative . /4 Y <br /> TYPE OF SERVICE REQUESTED : l7 CEi v <br /> COMMENTS : <br /> SAN JOA uL ° s ?020 <br /> L HEgLTH p pgENTq� TY <br /> RTN)ENT <br /> ACCEPTED BY: y EMPLOYEE #: DATE : n tt <br /> ASSIGNED TO : , A I EMPLOYEE #: �( Li � DATE : "7 � �iV <br /> V ° d ea <br /> V <br /> Date Service Completed ( if already completedi. SERVICE CODE: q PIE : <br /> Fee Amount: (9 Amount Pai TSCA D Payment Date 1161200 <br /> Payment Type s (� Invoice # Check # L� / ec ived By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />