COMPLIANCE INFO_2023 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Fueling Facility (A 00 3 60 S R mG B 7 4 Coq OWNER / OPERATOR Costco Wholesale Corporation CHECK if BILLING ADDRESS FACILITY NAME Costco 658 SITE ADDRESS 3250 W Grantline Rd . Tracy 95304 3250 Street Number Direction I Street Name City Zin Code HOME or MAILING ADDRESS ( If Different from Site Address) /q Y!I A N Street Number Street Name / V, • 7" CITY STATE ZIP 1Z I F_ p PHONE #1 EXT, APN # LAND USE APPLICATION # y Z62 �3 ( 209 ) 834- 1247 a 3 g — (p - SAN JOA PHONE #2 EXT, BOS DISTRICT Lftli4f, >p ENT L ( ) m0 5 Cd PAST ENr CONTRACTOR / SERVICE REQUESTOR REQUESTOR Bruno Espinoza - Jones Covey Group , Inc . CHECK If BILLING ADDRESS BUSINESS NAME Jones Covey Group , Inc . PHONE # EXT. 909 543 - 8904 HOME or MAILING ADDRESS FAX # 8595 Lucas Ranch Road # 100 ( 909 ) 484- 0300 CITY Rancho Cucamonga STATE CA ZIP 91730 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 . 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 : DATE : 11 /20/2023 PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Jones Covey Group - Permitting If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , 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 environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It Is provided t0 me or my representative . TYPE OF SERVICE REQUESTED : COMMENTS : UDC #23/24 Brine leak at manometer fitting inside UDC . Need to repair with Bravo Fiberglass Glue Kit. PN : BR- K-402 ACCEPTED BY : <� I 'r� EMPLOYEE # : DATE: 1120 Z'5 ASSIGNED TO : lJ EMPLOYEE # : DATE: Z � L� Date Service Completed ( if already completed ) : — SERVICE CODE: PIE : GPIE . Fee Amount : — Amount Paid �- Ob Payment Date IM/ 0 Payment Type Invoice # Check # I �ZS3 � Received By: EHD 48-02-025 SR FORM (Golden Rod ) 07/17/08