Laserfiche WebLink
DATE: <br />ERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El" <br />SAN JOAQUINOVUNTY ENVIRONMENTAL HEALTIOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Former UST location <br />FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />Diesel Performance Inc. CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Diesel Performance Inc. <br />SITE ADDRESS <br />2804 Street Number <br />East <br />Direction <br />m Fremont Street <br />Street Name Stockton <br />City <br />95205 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Ciry STATE ZIP <br />PHONE #1 EXT. <br />( 209 ) 946-0233 <br />APN # <br />143-430-08 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Jeanne Homsey CHECK if BILLING ADDRESS r4 <br />BUSINESS NAME <br />ATC Group Services LLC <br />PHONE # <br />( 209 <br />EXT. <br />)579-2221 <br />HOME or MAILING ADDRESS <br />1117 Lone Palm Avenue, Suite 201B <br />FAX # <br />( 209 ) 579-2225 <br />CITY Modesto STATE CA ZIP 95351 <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 <br />or activity will be billed to me or my business as identified on this form. <br />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 <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER El <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 <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 SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P/ E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003