SR0085874_SSNL - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Gas Station / Convenience Store / Car Wash FA0007821 PHONE# 925 S R, 00 d 5 8 -7 4 OWNER /OPERATOR Blackhawk Management Group, LLC CHECK if BILLING ADDRESS FACILITY NAME Proposed ARCO & AM/PM SERVICE CODE: S Z SITE ADDRESS 7`500 W I Eleventh Street ) Tracy 95304 Street Number Direction Street Name Received By: Citv Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 2605 Camino Tassajara Lane, #1582 I Street Number Street Name CITY Danville STATE CA Z'P 94526 PHONE #1 EXT. APN # 250-150-16, 17, 18 LAND USE APPLICATION # ( 925) 548-7910 PA -2100275 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Edgar Hickallah RECEIVED CHECK if BILLING ADDRESS BUSINESS NAME Blackhawk Management Group, LLC 9 p EMPLOYEE #: PHONE# 925 EXT. 548-7910 HOME or MAILING ADDRESS DATE: FAX# SERVICE CODE: S Z 2605 Camino Tassajara Lane, #1582 P 1 E- (a 0 2 ( ) CITY Danville STATE CA ZIP 94526 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 FEDE 1 ws APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER✓❑ OPERATOR / MANAGER OTHER AUTHORIZED AGENT ❑ IfAPPL/CANT is not the BILLING P.4RTF, 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 environmentaUsite assessment infoinlation 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. PAYMFNT TYPE OF SERVICE REQUESTED: Review of Soil Suitability/Nitrate Loading Study RECEIVED COMMENTS: O r 0 5 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: .1[0/5 2 Z I ASSIGNED TO: 1 d�rt -tl EMPLOYEE #: �f DATE: Date Service Completed (if already completed): SERVICE CODE: S Z P 1 E- (a 0 2 Fee Amount: 2 Amount Paid 2 Payment Date O r5/2 Payment Type ') Invoice # Check # b C Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003