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SAN JOAQ COUNTY ENVIRONMENTAL HEALTL PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station ::LA OO I 5960-?'?I i L <br /> OWNER/OPERATOR <br /> Jesus Jurado CHECK 11 BILLING ADDRESS 0 <br /> FACILITY NAME Gas 4 Less <br /> SITE ADDRESS„< Mantheyd, Stockto CA 95206 <br /> Q Street Number n re Name CI I C e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number treat Namy <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#T ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS � <br /> BuSINEss NAME Service Station Systems, Inc. PHONE# ExT. <br /> 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 same, <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 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: R� t t�l�-�` •_'✓c (�.til 1��� DATE: 9/3/2015 <br /> PROPERTY/BUSINESS OWNERM OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 Compliance Officer <br /> If APPLICANT is not the BILIJNG PARTY,proof of authorization to sign is required Tire <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 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 in ction �j n AqY <br /> COMMENTS: <br /> J°4008�01s <br /> ACCEPTED BY: / EMPLOYEE#: DATE: <br /> ASSIGNED TO: / EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): 1?2 15 SERvICE CODE: P 1 E: O� <br /> Fee Amount: D, Amount Pa 3 /O v� Payment Date f /S <br /> Payment Type g9% Invoice# Check# S�j3 Re slued By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />