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SAN JOAPIN COUNTY ENVIRONMENTAL HEALT•EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .v <br /> gas station �.(T �-�— Ste-60 (p 3/ 3 <br /> OWNER 1 OPERATOR <br /> Hardeep Gill CHECK If 13ILl1N0 ADDRESS❑ <br /> FAC'UTYNAME Fast Lane Gas(Central Valley) <br /> $READDRESS 116 E Roth Rd, athrop C 95330 <br /> Stroll,s r. Number GIN Zip C9de <br /> HOME or MAILING ADDRESS (if Different from SRe Address) <br /> Sb••I Number lml <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> l 1 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CNECKHBILONG ADDRESSM <br /> BUSINESS NAME Able Maintenance, Inc PHONE# EYr• <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAII# <br /> (408 ) 213-6026 <br /> CIT' 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 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: p 6 a (i-`/ DATE: 7/28/2011 <br /> PROPERTY/BUSINESS OWNERM OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E) Compliance Officer <br /> IfAPPLIG4NT is not the BILIJNG P,4RTy,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 SERVICEREQUESTED: UST inspection <br /> COMMENTS: RECEIVED <br /> JUL 2 9 2011 <br /> SAENVIIROTM <br /> ENVIRONMENTAL <br /> V <br /> .-r�� TH DEPARTMENT <br /> ACCEPTED BY: L..LiLti'' EMPLOYEE#: qL)5 DATE; 712-q <br /> ASSIGNED TO: EMPLOYEEM cf� DATE:7/29 /11 <br /> Date Service Completed (M already completed): SERVICE CODE: Gl9> PI'E: 23Q9 <br /> Fee Amount: &OU Amount Paid 3 — Payment Date <br /> '1 a Z/ L <br /> Payment Type t/ Invoice# Check# _ Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />