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SAN JOAQt tN COUNTY ENVIRONMENTAL HEALTH�EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE�REQUEST If <br /> gas station 15-7-76 4 oe & I/Qvo <br /> OWNER/OPERATOR <br /> Hardeep Gill CHECK It BILLING ADDRESS❑ <br /> FACILITYNAMEFastlane Gas(Central Valley) <br /> SITE ADDRESS 116 E Roth Rd. athrop C 95330 <br /> 3 nn NumMr a CI <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Streel Number tml N.Me <br /> CITY .STATE ZIP <br /> PHONE 01 En. APN R LAND USE APPLICATION a <br /> PHOME#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If BILLING ADDRESS <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# En• <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAz# <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 laws. <br /> APPLICANT'S SIGNATURE: t' �t ( t i Ef J(,1-6-t(> DATE: 6/21/2012 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E) Compliance Officer <br /> 1fAPPLICWT is no/the BIGJIJG 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST inspection 4zeiV—elF"/ -7— <br /> COMMENTS: PAYMENT <br /> RECEIVFr) <br /> JUN 15 2011 <br /> SANJoaovrv,ccu <br /> EHYIRCNMFHr Ml' <br /> ACCEPTED BY: 0(-.t f1l�l � EMPLOYEE#: 032— DATE: 2S' <br /> ASSIGNEDTO: EMPLOYEE#: '2&, 4,5 DATE: 6125:11 2_ <br /> Date Service Completed (N already completed): SERVICE CODE: V.� PIE: 23 De <br /> Fee Amount: 3 7,f. c) Amount Paid Payment Date <br /> Payment Type L,V,,eL Invoice# Check# Recelved B : <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />