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SAN JOAQUIN ll wdNTV ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station b6-�5V 7 S�0V 7 U —7 <br /> OWNER/OPERATOR <br /> CHECK I}BILUNO ADORES <br /> Jessie Bola <br /> S <br /> FACILITY NAME Woodbridge Arco <br /> SITE ADDRESS 18806 Lower Scramento d, Woodbridge CA 95258 <br /> Street N EIM11 Nam City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Numbr el Na <br /> CITY STATE ZIP <br /> PHONE#1 E"' APN# LAND USE APPLICATION# <br /> ( I t, <br /> PHONE#2 Ems' SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECKtf BILLING ADDRESSO <br /> BUSINESS NAME PHONE# Ela, <br /> Service Station Systems, Inc. 4081 213-6038 <br /> HOME or MARINO ADDRESS 680 Quinn Ave FAX# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site find/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 /> 1 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 FEDERA� laws. <br /> APPLICANT'S SIGNATURE: / ( -4UT 1 l CL d t DArE: 7/28/2016 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHERAUTHORILEDAGENTQ Compliance Officer <br /> 1f APPLICANT is no1 fNe BILIJNG PARTY,proof of authorization to sign is required Title <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 10 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. <br /> TYPE OF SERVICE REQUESTED: UST inspection <br /> COMMENTS: 1VF0 <br /> 62018 <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1�7-/ _ <br /> ASSIGNED TO: Z EMPLOYEE#: DATE: / _/ <br /> Date Service Completed (If already completed): SERvICECODE: 9 PIE: <br /> Fee Amount: 14) OJ Amount 1'.dV Payment Date <br /> Payment Type ✓ Invoice If Check# u, Received By: MV <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />