Laserfiche WebLink
1 . r <br /> SAN JOA* COUNTY ENVIRONMENTAL 1'IEALAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 9 SERVICE REQUEST# <br /> gas station r 14 <br /> OWNER 1 OPERATOR 1 1 <br /> PAID Inc. CHECI(t(BILLING AppRESS❑ <br /> FACILITY(NAME Rancho San Miguel (Food 4 Less) <br /> SITE ADDRESS W4 ,2 9-S.Airportay Stock on CA 95206 <br /> Street Number n e city e <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Strost Nsmp <br /> CITY STATE. ZIP' <br /> PHONE 91 ExT. APN I LAND USE APPLICAnoN M <br /> ( 1 <br /> PHONE02 EXT. SOS DISTRICTLOCATION CODE <br /> { I 1 71 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If BILLINGADDRESSEI <br /> BUSINESS NAME Service Station Systems, Inc. PHONEN EXT. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAx III <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING A f KN—QWLEDL'j&M01: I, 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 211 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEn6RAL laws. <br /> L' _ 611512012APPLICANT'S SIGNATURE: : <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHERAUTHORIzEDAGENT❑ Compliance Officer <br /> IfAPPLICANT is not the BILL/NG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE 1NFORMAT1,�1f N: 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 same time it is <br /> provided to me or my representative. F4 AgMENT <br /> TYPE OF SERVICE REQUESTED: UST inspection RECEIVEDn{ <br /> COMMENTS: `UM,I 19 2012 <br /> S4N.lOA4UrN cnUlm <br /> HEALTx bEPPJ:"ENT <br /> ACCEPTED BY: { EMPLOYEE M DATE: <br /> ASSIGNED TO: t EMPLOYEE M. DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (' P 1E: <br /> Fee Amount: ']� Amount Paid r "7 ( Payment Date <br /> Payment Type L Invoice# Check 0 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 712 00 3 <br />