COMPLIANCE INFO_2011-2018 - Laserfiche WebLink

Home Browse Search

SANtJOAQUIA 19F311'r 0 qFVVICE CONTRACTOX I NERV 1�-r 'trY u r101 "1 REQUESTOR Carl Wayne Henderson CHECK If BILLING ADDRESS 364187 91 PHONE# ExT. BUSINESS NAME Service Station Testing - SST INC ( 209 ) 465-5577 FAX# HOME or MAILING ADDRESS PO Box 31465 (209 )465-4988 CITY Stockton STATE CA 73P 95213 BILLING AG)WLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, HEALTH DEPARTMENT hourly charges associated with this project acknowledge that all site and/or project specific ENVIRONMENTAL HE 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: I/ I — - H DATE: 8/14/13 PROPERTY I BUSINESS OWNER13 OPERATOR/ MANAGER 13 OTHER AUTHORIZED AGENT11a President the BILLING PARTY proof of authorization to sign is required Title If APPLICANT is not AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the site assessment above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ 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: CommENTs: Remove Tank Gard system and install TSL -300 & 2 ea 420 sensors. ACCEPTED BY: ASSIGNED TO: Date Service Completed (if already completed): Fee Amount: Amount Paid Payment Type I invoice# EHD 48-02-025 REVISED 11/17/2003 EMPLOYEE M EMPLOYEE M SERVICE CODE: Payment Date Check # DATE: DATE: PIE: Received BY: SR FORM (Golden Rod)