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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station �00 tj J 2 �� 12C)2— <br /> OWNER/OPERATOR <br /> Raleys CHECK If BILUNO ADDRESS <br /> FACILITY NAME Raleys <br /> SITE ADDRESS 4219 Morada Lne, Stockt n CA 95212 <br /> Stn t Number n re arae city I e <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# IL L] )LLAND 15E APPLICATION# <br /> PHONE#2 ExT• iJI! BOS DISTRICT _ Toc <br /> ATION CODE <br /> C) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECKIf BILLING ADDRESSO <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Systems, Inc. 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 project <br /> or activity will be billed to me or my business as identified on this form. <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 Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: j �� _ 1 `'° �.:I L L d L 'L-1-L)L_L DATE: 5/17/2018 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER❑ OTHERAUTHORIZEDAGENT O Compliance Officer <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 epi t��assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avail) a time it is <br /> c provided to me or my representative. RE <br /> ICE EQLIESTED: UST inspection JUN 0 4 2018 <br /> COMMENTS: <br /> SA <br /> JUN 1, �01� N JOAQUIN COUNTY <br /> 't ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> I�:NN'1110NNIFNTAL 1!F k1lil <br /> I-, ��IZI'\11:N I <br /> ACCEPTED BY: (, EMPLOYEE#: DATE: <br /> ASSIGNED TO: `. 7 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: ,L <br /> Fee Amount: t �' Amount Paid '� Payment Date (p Ll <br /> Payment Type Invoice# Check# lt��j Received By <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />