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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> 6ERA <br /> siness or Property FACILITY ID# SERVICE REQUEST A <br /> tion LFL 7 kiWO& 13&O <br /> OPERATOR CHECK If BIW NG ADDRESS <br /> B&G Group Inc <br /> ME Fast Lane Central Valley <br /> SS 116 E Roth Rd. athrop C 95330 <br /> Slr •t umb•r OAILING ADDRESS (If Different from She Address) 111 Healdsburg AveStmtNumtwr in•tldsburg STATE CA ZIP 95448 <br /> HONEEm' APN a LAND USE APPLICATION s <br /> ( 707-431-3510 <br /> PRONE#2 En. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# �T• <br /> Service Station Systems, Inc. 408 213-6038 <br /> HOME Or MAILING ADDRESS FAX 11 <br /> 680 Quinn Ave (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 /> 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 laws. <br /> APPLICANT'S SIGNATURE: 11 L;Lti (,L,L— L ` 6 t cci; DATE: 11/2/10 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Compliance Officer <br /> /fAPPL1CANT is not the BILLING PARTY.proof of authorization t0 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. -11: 1 <br /> TYPE OF SERVICE REQUESTED: UST inspection GEIV E� <br /> COMMENTS: <br /> I, N�VJD ROHtMEMTAL� <br /> �rlTM DeP1,RTME1n <br /> r1t�L <br /> ACCEPTED BY: IIS EMPLOYEE#: / DATE: <br /> ASSIGNED TO: - EMPLOYEE M. <br /> /„ DATE: <br /> Date Service Completed ( ready completed): SERVICE CODE: P I E:17 a <br /> Fas Amount: Amount Paid -*3 (.(..ob Payment Date IL 13 1-0 <br /> Payment Type Invoice# Check# �, Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />