Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # _- <br /> Gasoline Dispensing Facility000 37 50 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Valero Hammer Lane <br /> FACILITY NAME <br /> Valero Hammer Lane <br /> SITE ADDRESS 1210 E Hammer Lane Stockton 95210 <br /> Street Number Direction I Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT• AP # LAND USE APPLICATION # <br /> 209 ) 715- 0124 3 <br /> PHONE #2 EXT• BOS DISTRIC n LOCATIOODE <br /> oo <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Janelle Dockham CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME PHONE # Exr' <br /> Confidence UST Services ( 661 631 -3870 <br /> HOME or MAILING ADDRESS FAX # <br /> 2209 Zeus Court ( 661 ) 587-9758 <br /> CITY Bakersfield STATE CA ZIP 93308 <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 law/s, <br /> APPLICANT' S SIGNATURE : ga4t4.& 7�eclr m DATE : 09/14/2021 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Permit Clerk <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tire <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 . Q <br /> awl JZ1VT <br /> TYPE OF SERVICE REQUESTED ; ' f MEFCF <br /> COMMENTS : SEP <br /> SA N �O 221 <br /> A <br /> NEA THI FARTo�NTy <br /> MENT <br /> ACCEPTED BY: l� /���� EMPLOYEE #: DATE: <br /> ASSIGNED TO : v ' O D EMPLOYEE # : DATE. <br /> Date Service Completed ( if already completed) : SERVICE CODE: l f 2174? PIE : <br /> Fee Amount : 61VAmount Pai C f ` � Payment Date <br /> Payment Type Invoice # Check # / 317Z 2Receiv d By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />