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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property i ' FACILITY ID # SERVICE REQUEST # gas station 13503 BuslNEss NAME Service Station Systems, Inc. soe/)_ 0o-kC> 1j &b OWNER /OPERATOR EXT. Safeway Inc. CHECK IfPILUNGADDRESSO FACILITY NAME 213-6038 Safeway DATE: 30 SITE ADDRESS SERVICE CODE: / 9 Si P f E: (408 ) 213-6026 1987 W 11th St eet, Tracy CA 95376 I Invoice # Check # 2-33 Street Number n lI Stratte e CI HOME or MAILING ADDRESS (If Different from Site Address) 5918 Stoneridge Mall Rd Street Number tree( Na CITY Pleasanton STATE CA ZIP 94588 PHONE #1 ExT. APN 11 LAND USE APPLICATION # ( 925-467-2707 232-170-26 PHONE #2 Em. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR RECIUESTOR i ' `, C _ 1 �•,•!;___ Marty Weithman COMMENTS: CHECK If BILLING ADDRESS BuslNEss NAME Service Station Systems, Inc. PHONE EXT. DATE: ASSIGNED TO: 408 213-6038 HOME or MAILING ADDRESS 680 Quinn Ave DATE: 30 FAx # SERVICE CODE: / 9 Si P f E: (408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNOWLEDGEMENT: 1, 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: /1, y{ �i - % Q . � t,t,�.� �J DATE: 6/29/10 PROPERTY/ BUSINESS OWNERM OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT D Compliance Officer IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 provided to me or my representative. TYPE OF SERVICE REQUESTED: UST inspection ;�( ��_7 i ' `, C _ 1 �•,•!;___ COMMENTS: !1L .�ulV 3 0 Lu it) ENVIROI'�i'k! ll Ht'-:A!:FH ACCEPTED BY: EMPLOYEE DATE: ASSIGNED TO: EMPLOYEE #: / DATE: 30 Date Service Completed (if already completed): SERVICE CODE: / 9 Si P f E: Fee Amount: 3 Amount Paid 13 Payment Date &13 D Payment Type Invoice # Check # 2-33 Received By: �� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003