Laserfiche WebLink
SAN JOAQMfN COUNTY ENVIRONMENTAL HEALTHEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property nFACILITY IDM SERVICE RIEJpUEST R I <br /> ,�-gas station <br /> OWNER/OPERATOR <br /> Jesus Jurado CHECK If BILLING ADDRES9� <br /> FACILITY NAME Rancho San Miguel <br /> SITE ADDRESS 610 S Cheroke Lane, Lo i <br /> SIn�I Numbr re N.MJ city X10 < <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> SmW N.mbr strt.t N. <br /> CITY STATE ZIP <br /> PHONE M1 E^. APN a LAND USE APPLICATION M <br /> l 1 <br /> PHONE M2 En. SOS DISTRICT LOCATION CODE <br /> ( i <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK It BILLING ADDRESS0 <br /> BUSINESS NAME Service Station Systems, Inc. 1408 <br /> EXT.213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAZM <br /> (408 1 213.6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 ;_ , f <br /> i . : e !. A_ L a ' DATE: 1 N / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AIrrHORIZEDAGENT P) Compliance Officer <br /> IfAPPL/CANT is not the BILLING PARTY.proof of authoritation to sign is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 sitli'tlt <br /> provided to me or my representative. fl?c,F/ ^t <br /> TYPE OF SERVICE REQUESTED: UST inspection —T RellrTDA J4N <br /> COMMENTS: SV <br /> O <br /> FryRN <br /> HEOO �C00 <br /> ryKL <br /> EYr <br /> ACCEPTED BY: EMPLOYEE M: DATE: <br /> ASSIGNED TO: EMPLOYEE M: DATE: <br /> Date Service Completed (It already completed): SERVICE CODE: (a PIE: ZJ <br /> — 64 <br /> Fes Amount: Amount Pal 3qQ Payment Date <br /> Payment Type Invoice M Cheek M .S(�.5.�-- Received ay; <br /> EMO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/200 <br />