COMPLIANCE INFO_2011-2018 - Laserfiche WebLink

Home Browse Search

SAN JOAQUII OUNTY ENVIRONMENTAL HEALTH DEPARTMENT Y t SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAMEPHONE Service Station Testing - SST INC REQUEST # GDF 5b K EMPLOYEE #: �6 7c) nSERVICE S (-0007-791 OWNER/ OPERATOR Tulare Farms, LLLP CHECK if BILLING ADDRESS❑ FACILITY NAME Tulare Farms, LLLP (was Ace Tomato) CITY Stockton SITEADDRESS 2771E French Camp Rd PIE: Z3 O Manteca 95336 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE CA ZIP PHONE #1 EXT APN # LAND USE APPLICATION # ( 209 ) 235-3055 ®� PHONE #2 EXT. BOS DISTRICTLOCATION CODE ( ) 06 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson 187 CHECK if BILLING ADDRESS® BUSINESS NAMEPHONE Service Station Testing - SST INC SL -300 & 2 ea 420 sensors. M�JlVT 6 AUC'l 52013 S qv A(Efvv,) U/� CC t,E �crI-1 B��A R�AI'�1 i° # EXT. ( 209 ) 465-5577 HOME or MAILING ADDRESS EMPLOYEE #: �6 7c) FAX # PO Box 31465 ( 209 ) 465-4988 CITY Stockton STATE CA ZIP 95213 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 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: L � DATE: 8/14/13 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® President If APPLICANT is not the BILLING PARTY—proof of authorization to sign is required Title 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: �y/� 4 PA COMMENTS: Remove Tank Gard system and install SL -300 & 2 ea 420 sensors. M�JlVT 6 AUC'l 52013 S qv A(Efvv,) U/� CC t,E �crI-1 B��A R�AI'�1 i° ACCEPTED BY: 1 A lh EMPLOYEE #: �6 7c) DATE: S f ASSIGNED TO: PF�"� EMPLOYEE #: ' O_. f DATE: Date Service Completed (if already complet SERVICE CODE: / 2 9 1 PIE: Z3 O Fee Amount:+—? -'1 - Amount Pai 3'75. &D Payment Date Payment Type Invoice # Check # /1,337 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003