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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDR= SERVICE REQUEST p <br /> gas station <br /> OWNER I OPERATOR <br /> Raleys CHECK If BILLING ADORES <br /> FACILITY NAME Raleys <br /> SITE ADDRESS 4219 Morada Lne, Stockt n CA 95212 <br /> Sl et NumMr n SJ.,I Neme CIN Zip Code <br /> HOME or MAILING ADDRESS (I}Different from Site Address) <br /> Street Number tree/Ne <br /> CITY STATE ZIP <br /> PHONEM En. APN# LAND USE APPLICATION It <br /> PHONEII2 En' SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weinman CHEEK If BILLING ADDRESSO <br /> BUSINESS NAME Service StatlDn S Stems, IDC. PHONEII EXT. <br /> y 408 1 213-6038 <br /> HOME or MAILING ADDRESS 680 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 projecl <br /> or activity will be billed to me or my business as identified on this farm. <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinonce Codes,Standards,STATE and FEDERALlaws. <br /> APPLICANT'S SIGNATURE:/� tSr(( et, UO ti •jt,.1Xet-A-LLAL-Li DATE: 5/17/2018 <br /> PROPERTY/BUsiNEss OwnRO OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT +❑ Compliance Officer <br /> JfAPPLICIAT is not the BILLING P.4,R 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 /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02.025 SR FORM (Golden Rod) <br /> REVISED 1111712003 <br />