Laserfiche WebLink
SAN JOAt�J1N COUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST p <br /> gas station 1597'1 2(o 9 00 <br /> OWNER/OPERATOR <br /> Hardeep Gill CHECK If BILLING ADDRESS <br /> FACILITY NAME Fast Lane Gas <br /> SHE ADDRESS 116 E Roth Rd, athrop Ci 95330 <br /> Sleet Numinr r cit, <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Stnrl NumOer steest Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN/ LAND USE APPLICATION Y <br /> PHONE$2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK It BILLING ADDRESS <br /> BUSINESS NAME Able Maintenance, Inc PHONE Err. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAxA <br /> (408 ) 213-6026 <br /> CIT' 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: �2(CC.L 2-I_' (' ' t t 1t DATE: 6/7/2011 <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Q Compliance Officer <br /> 1jAPPLJC4NT is not the R7LLING 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 ame time it is <br /> provided to me or my representative._ <br /> TYPE OF SERVICE REQUESTED:UST inspection(already Q completed) <br /> COMMENTS: _ 3 Io to •O e e O <br /> U SpN"N "00 itPPPtM�NS <br /> I _ H�PL1N <br /> ACCEPTED BY: EMPLOYEE -yd ST DATE: /9/// <br /> ASSIGNED TO: ✓✓✓���"' EMPLOYEEM .2-GrFL DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: lq� PIE: 230& <br /> Fee Amount: -O 0 Amount Paid rs, ZZ r t-;o Payment Date �1 <br /> Payment Type ✓ Invoice iF Check If � � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 *11D BkLA'!vCe Z)�' <br />