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SAN JOAQL„i COUNTY ENVIRONMENTAL HEALTH —k;PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station i3�-o3 2CLv <br /> (� <br /> OWNER/OPERATOR <br /> Safeway Inc CHECK If BILLING ADDRESS <br /> FACILITY NAME Safeway <br /> SITE ADDRESS 1801 W 11th Stracy CA 5376 <br /> Street Num roytion SiroldName city 41, <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If BILLINGADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Service Station Systems, Inc 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave Fax# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 I 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:11(� ',u,L ,.I DATE: 10/7/2014 <br /> PROPERTY/BUSINESS OWNERM OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 Compliance Officer <br /> 1f APPLICANT is not the BlLLINGPARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TOER LEASE INFORMATION: 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. <br /> TYPE OF SERVICE REQUESTED: UST inspection PAYMENT <br /> COMMENTS: OCT V 9 2m <br /> SARI JOAQUIN COUWr <br /> ENVIRONMEWAI. <br /> HEALTH DEPARTMqWr <br /> ACCEPTED BY: , EMPLOYEE#: ��YS DATE: r� <br /> ASSIGNED TO: / EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P/E:0730 <br /> Fee Amount: Amount Paid 3 Payment Date %d _ l� <br /> Payment Type Invoice# Check# l Recelved By- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />