Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST# <br />gas station <br />CHEGN1f BIWNIT-ADDRESS <br />BUSINEss NAME <br />Service Station Systems, Inc. <br />�� I I — <br />OWNER I OPERATOR <br />T• <br />Safeway <br />CHECK'If131Luxo APDRESS <br />FAcurT NAME Safeway #2600 <br />213-6038 <br />SITE ADDRESS 1987 W 11th Stracy <br />CA <br />5376 <br />680 Quinn Ave <br />stt Numbe r <br />ree <br />) 213-6026 <br />CITY San Jose <br />Name <br />clix <br />Zle <br />HOME or MAILINO ADDRESS (if Different from Site. Address) <br />Street Number <br />stree0jame <br />CITY <br />STATE ZIP <br />PHONE#1 EXT. APN # <br />LAND USE APOuCATION # <br />PHONE42 ENT, <br />BOS DISTRICT _ LOCA*nOM CODE. <br />CONTRACTOR / SERVICE REQ:UESTOR <br />REQUESTOR <br />✓ <br />Marty Weithman <br />CHEGN1f BIWNIT-ADDRESS <br />BUSINEss NAME <br />Service Station Systems, Inc. <br />PHONE# <br />T• <br />408 <br />213-6038 <br />HOME Or MAILING ADDRESS <br />FAXJ <br />680 Quinn Ave <br />.:(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLINGACKNOWLEDGEMENT: 1; the undersigned prpperty or business• owner, operator or authorized agent ; f same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT lburly 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 l have prepared this application and that.the work to be performed will be done in accordance with 411 SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL law$. <br />APPLICANT'S SIGNATURE: 14 .'h btkn �,�,J V DATE: 6/10/2018 <br />PROPERTY IBUSINESS OwNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ Compliance Officer <br />IfAPPL1CANT is not the BxL1NG PjRTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFQRMATION: When applicable, I, 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 environtn"tai/siteAssessmIent <br />information to the SAN JOAQ11IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as -it is available and.at the sa ,X .t,is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: UST inspection <br />COMMENTS: <br />S AIV q1N <br />'14 7?0)V <br />ACCEPTED BY: /1 I EMPLOYEE #: I LATE: <br />ASSIGNED TO: l�f tf EMPLOYEE M DATE <br />Date Service Completed (If already Completed): SERYICECODE: r P fE.- ,J? <br />Fee Amount: �k� C}` Am,ount P 4 Payment Date �/M <br />Payment Type Llf,�;� Invoice # Ch k #�n�� Receive : By: <br />EHD 48-02.025 SR FORM (Goldejn Rod) <br />REVISED 11/17/2003 <br />