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r , <br /> SAN JOAQ1"" COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station -1 I <br /> OWNER/OPERATOR 1 D <br /> Jesus Jurado CHECK If BILLING ADDRE$S <br /> FACILITY NAME Gas 4 Less <br /> SITE ADDRE anthey d, Stockto CA 95206 <br /> D <br /> Street Number rec n - S(revj Name city T zi.Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street NumlxTr troel Name <br /> CITY STATE zip <br /> PHONE#1 Err. APN# LAND USE APPLICATION t•-- <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS El <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# ExT• <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS FAX# <br /> 680 Quinn Ave <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLED(;EMENT: 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 /> 1 also certify that l 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:IL(rc L—ta-L.,Lk kms( L i.l �l, DATE: 2/10/2015 <br /> 1 <br /> PROPERTY/BUSINESS OWNERM OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Compliance Officer <br /> YAPPLICANT is not the BILLIAIG PARTY,proof of authorization to sign is required Titte <br /> AUT)IORIZATION TO RELEASE 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 <br /> COMMENTS: <br /> vC <br /> ACCEPTED BY: EMPLOYEE#: DATE:G'V( <br /> ASSIGNED TO: (y Ll�� l ' �� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: l P I E: �?zc <br /> Fee Amount: $.7cI - C:C' I Amount Pa/037b,da Payment Date r is <br /> Payment Type Invoice# Check# 57(,F Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />