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SAN JOAQL -"OUNTY ENVIRONMENTAL HEALT EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # REQUESTOR SERVICE REQUEST # CHECK if BILLING ADDRESS JEFFREY LEE L 3 COMMENTS: Sr 0 C) &gam GAS STATION PHONE # -I-c-3 HOME or MAILING ADDRESS 586 HIGUERA STREET SUITE 200 OWNER / OPERATOR CITY SAN LUIS OBISPO STATE CA CHECK If BILLING ADDRESS El STAN OLEA c/o SAFEWAY, INC. FACILITY NAME SAFEWAY FUEL CENTER #2600 SITE ADDRESS 1987 WEST11th STREET ��3 7J TRACY 95376 Street Number Direction S �� -� DATE: 3 /1? Street Name SERVICE CODE: city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 5918 STONERIDGE MALL ROAD Payment Date 5 0 Street Number Invoice # Street Name CITY PLEASANTON -L Received By: STATE CA Zip 94588 PHONE #1 ExT. APN # LAND USE APPLICATION # (925 ) 467-2707 232-170-24a PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) C''nNTR ACTOR /,SERVICE REOUESTOR v v ` ' — v — — — REQUESTOR TYPE OF SERVICE REQUESTED: CHECK if BILLING ADDRESS JEFFREY LEE AZt4T COMMENTS: BUSINESS NAME LHB &ASSOCIATES PHONE # ExT'805 540-5240 HOME or MAILING ADDRESS 586 HIGUERA STREET SUITE 200 FAX # (805)540-5241 CITY SAN LUIS OBISPO STATE CA Zip 93401 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this applic on and that t#e work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Sta ards, KFEDJEk4 laws.APPLICANT'S SIGNATURE: DATE: ls�l��PROPERTY /BUSINESS OWNER❑ P O ❑ OTHER AUTHORIZED AGENT f� PROJECT ENGINEER/MANAGER If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is .:,7 A ♦, — Pn — tativP PrGVLU ,. .0 w ...., .,....J .................... _. TYPE OF SERVICE REQUESTED: -j� —YZ e, F l AZt4T COMMENTS: SANN�pEPARTM�NT F�- ACCEPTED BY: JL t u a t t2A EMPLOYEE #: ��3 7J DATE: L9C> '— ASSIGNED TO: JQ EMPLOYEE #: S �� -� DATE: 3 /1? Date Service Completed (if iready completed): SERVICE CODE: P / E: 2—` ,3,-,, Fee Amount: - `� l Sc�tl Amount Paid — Payment Date 5 0 Payment Type Invoice # Check # -L Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003