Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station <br /> OWNER/OPERATOR <br /> Raleys CHECK 1}BILLING ADDRESS <br /> FACILITY NAME Relays <br /> SITE ADDRESS 4219 Morada L ne, Stockt n CA 95212 <br /> Str, Numbr ro eme CiN Zip Code <br /> HOME or MAILING ADDRESS (if Different from Slte Address) <br /> Slroel Numbr iroel Ne <br /> CITY STATE LP <br /> PHONE#1 Ev. APN0 LAND USE APPLICATION it <br /> f 1 <br /> PHONE#T En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK It BILLING ADDRessEl <br /> BUSINESS NAME PHONE# Ev. <br /> Service Station Systems, Inc. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 660 Quinn Ave FAX# <br /> (408 ) 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 same, <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:It( a.�L L,i �- `V'. LLUt L v DATE: 5/17/2018 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E] Compliance Officer <br /> IfAPPL/CANT is not the BILLING 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 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. <br /> TYPE OF SERVICE REQUESTED: UST inspection <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Data Service Completed (I}already completed): SERNCE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice III <br /> Check# Received By: <br /> EHD 46-02.025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />