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SAN JOAQ.IN COUNTY ENVIRONMENTAL HEALTIi i1EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />PA <br />FACILITY ID # <br />REQUEST # <br />gas station <br />CHECK if BILLING ADDRESS <br />3 17SrE—RVICE <br />0 5�24S- <br />OWN !R /OPERATOR <br />EXT. <br />CHECK If <br />Safeway <br />408 <br />SILUNG ADDRESS <br />FACILITY NAME Safeway <br />DATE: <br />sk4hv <br />FAx # <br />680 Quinn Ave <br />PIE: <br />SITE ADDRESS <br />Amount Paid <br />SS, <br />Payment Date 1'7/ / U <br />Payment Type i/ <br />(408 <br />► 213-6026 <br />CITY San Jose <br />1987 W 11th st <br />racy, CA5376 <br />Straat Number <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 5918 <br />Stoneridge Mall Rd <br />Street NumWr <br />treat Na <br />CITY Pleasanton <br />STATE CA zip 94588 <br />PHONE #t ExT. APN fi <br />LAND USE APPLICATION # <br />( 925-9467-2707 �Z 3 2 - <br />170-2-6 <br />PHONE #2 Ext. <br />BOS DISTRICTLOCATION CODE <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Marty Weithman <br />PA <br />COMMENTS: <br />R <br />9A,�4.� <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Service Station Systems, Inc. <br />SAN 10AQU1� T HEALTH <br />PHONE# <br />EXT. <br />ACCEPTED BY: 0 C t y t 0" <br />EMPLOYEE <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />DATE: <br />sk4hv <br />FAx # <br />680 Quinn Ave <br />PIE: <br />Amount: � <br />� <br />Amount Paid <br />SS, <br />Payment Date 1'7/ / U <br />Payment Type i/ <br />(408 <br />► 213-6026 <br />CITY San Jose <br />STATE CA <br />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 />I 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: lmou,�licl b- 'J ,QV�.DATE: 5/17/2010 <br />PROPERTY / BUSINESS OWNERM OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Compliance Officer <br />1fAPPLKANT is not the BiwNG PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE 1NFORMATJON: 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. i1ST -ry?-0 F l T <br />TYPE OF SERVICE REQUESTED: UST inspection <br />PA <br />COMMENTS: <br />R <br />9A,�4.� <br />�:otiu <br />SAN 10AQU1� T HEALTH <br />HV <br />PEflMiT/,ERVICES <br />ACCEPTED BY: 0 C t y t 0" <br />EMPLOYEE <br />DATE: s lel A 0 <br />ASSIGNED TO: 'e-9 i t/ <br />EMPLOYEE #: 1412-1 <br />DATE: <br />sk4hv <br />Date Service Completed (if already completed): <br />SERVICE CODE: (, <br />PIE: <br />Amount: � <br />� <br />Amount Paid <br />SS, <br />Payment Date 1'7/ / U <br />Payment Type i/ <br />Invoice # <br />Check # Z 2 is <br />Recelved By: NT_ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />