Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> SERVICE STATION Fj L00035 ' O <br /> OWNER 1 OPERATOR CHECK if BILLING AOORES,s [3 <br /> SP ARCO WEST COAST PRODUCTS LLC <br /> FACILITY NAME ARCO SS 6080 <br /> SITEAuDRESS 85 E LOUISE AVENUE LATHROP 95330 <br /> Street Number Dir"Ilon I stfoll Ime city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT, SUITE G <br /> Street Number ct"Al Mama <br /> CITY STATE ZIP <br /> DUBLIN CA 94568 <br /> PHONE M EXT, APN # LAND USE APPLICATION # <br /> ( 925 ) 551 .7555 <br /> PHONE #2 EXT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK If BILLING ADDRESS <br /> 00000 <br /> BUSINESS NAME GETTLER-RYAN , INC. PHONE # EXT. <br /> 925 551 -7555 <br /> HOME Or MAILING ADDRESS FAx # <br /> 6805 SIERRA COURT, SUITE G { 925 ) 5514886 <br /> CITY DUBLIN STATE CA zip 94568 <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned properly 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 : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ ' OPEILITOR I MANAGER ❑ OTIIER AUTHORIZED AGENT I�' Agen for owner <br /> If lIPPLICANT is not the BILLING PARTY, proof of ontllorization 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 environlnental/site assessment <br /> information to the SAN JOAQUI`N COUNTY ENVIRONMENTAL HCALTtt DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. r <br /> TYPE OF SERVICE REQUESTED: R 1SREN'$ER3 L� iq �7`7� <br /> MONEEMOSE <br /> COMMENTS : r <br /> REPLACE EXISTING DISPENSERS WITH NEW WAYNE OVATIONS WITH BALANCE SYSTEM �D <br /> APR 19 2022 <br /> sq <br /> 1 JL0A <br /> H, gtrIROQ N° uMry <br /> ACCEPTED BY` EMPLOYEE #: DATE: Zvir <br /> ASSIGNED TO : l S (D EMPLOYEE #: DATE% y 2 <br /> Date Service Completed (If already completed) : SERVICE CODE: _ < 9 S PIE: 2 , <br /> Fee Amount: �e f Lj� o L, Amount Pa(' C�'� p Payment Date ZZ _ <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17!21703 <br />