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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID K SERVICE REQUEST X <br /> gas station <br /> 1 - <br /> CWNER/OPERATOR �r <br /> Safeway Inc CHECK ffRiLLNoADORess <br /> FAcalrr NAME Safeway <br /> SITE ADDRESS 19 7 t <br /> Sim" <br /> HOME or MAluw ADDRESS (N Different from Site Address) S�)/ (- Stoneridge Mall Rd <br /> sh"tNufflitm <br /> CITY Pleasanton STATE CA zip 98001 <br /> PHONE 811 EXT. APN S LAND USE APFuCA'n0N 0 <br /> ( 925 1461-5555 <br /> PHo+E82 BOSDUMMCr LocATroNCooe <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR `� <br /> Oe 1� t' Laic_ CHECK BuM AMM � <br /> EV <br /> Buss,Ieas NAME Service Station Systems, Inc. 14o008>Y <br /> HOME or MAkiNo ADDRESS 680 Quinn Ave FAx g <br /> oa 1 D13- i <br /> CITY San Jose STATE CA ZIP 95112 <br /> �LWNG kCKNOR'LEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same, <br /> acknow)edge 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 idemlfied on this form. <br /> 1 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:� ��� _-- _ DATE: <br /> PROPLRTyIBUst>+rr:ssOwneRO OPERATOR/MANAGER❑ OTNzRAuTHoatzwAoriTO Compliance <br /> 1fAPP lcm7 is not the,BILLING Am proof of outharizadon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator ofthe property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite 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: <br /> RECEIVE. <br /> JUN - 7 201 <br /> SA.I? 10A111n,7, <br /> ACCEPTED BY: EMPLOYEE M `�C; DATE: � 7 <br /> ASS ION EDTO: } EMPLOYEEM DATE: 7 0 <br /> Date Service Completed (Df already completed): SERVICE CODE: cy PIE: �;L <br /> Fee Amount: __ Amount Paid 3 (o(c, — Payment Date b tit <br /> Payment Type Invoice# liehesit ty q 2q p -L Received By: <br /> EHD 48-02-025 SIR FARM(Golden Rod) <br /> REVISED 11/17/2003 <br />