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SAN JOA•IN COUNTY ENVIRONMENTAL HEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID k ll SERVICE REQUEST# <br /> gas station <br /> OWNER/OPERATOR !! <br /> B&G Group Inc CHECK It BILLING ADDRESa <br /> FACILITY NAME Fast Lane Central Valley <br /> SITE ADDRESS 116 E Roth Rd.kthrop C 95330 <br /> Sb• t NumMrSimt No.. CI <br /> HOME or MAILING ADDRESS (If DlRerent from Site Address) 111 Healdsburg Ave <br /> StrolNumber n•I <br /> CITY Healdsburg STATE CA ZIP 95448 <br /> PHONE#1 En' APN 11 LAND USE APPLICATION# <br /> 1 2538968700 <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK H BILLINGADDRESS� <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# �• <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAx# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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 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 haws. <br /> APPLICANT'S SIGNATURE: 6 ,-'t DATE: 12/6/2010 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT O Compliance Officer <br /> 1jAPPLICANT is no(the BiLL/NG PARTY proof of authorization to sign is required Title <br /> Q�ITHORIZATION 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 environmentallsite 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. Ll--&7 4—c F (—i P <br /> TYPE OF SERVICEREQUESTED: UST inspection ECEI T <br /> COMMENTS: utc 2010 <br /> JOAQLjIN <br /> EAL7}{Rp P�IINENT <br /> ACCEPTED BY: I U i EMPLOYEE#: C/F'�.3 if DATE: (' <br /> Z. -7 f O <br /> ASSIGNED TO: �_ /-J EMPLOYEE M Zfp fL b DATE: ( —7 f D <br /> Date Service Completed (H already completed): SERVICE CoDE:i 4� PIE. 23 0 <br /> Fee Amount: 3�G �� Amount Paid Payment Date <br /> Payment Type Invoice# Check* Z Recel d By: - <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />