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r <br /> SAN JOAQ,,,q COUNTY ENVIRONMENTAL HEALTH —ZPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station 1 �S ,n!09/3_2___ <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> Gilbert Silva <br /> FACILITY NAME Food 4 Less(Gas 4 Less) <br /> SITS a 3AS4Manthey d, Stockto CA 95206 <br /> .3 SlnetNumtxrDirpylign � Strept Name cityC e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> StreetNumber Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLINGADORESS <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 FEDERALI laws. <br /> APPLICANT'S SIG NATURE:���( _tt,� �I 1, t�i.tc�LL� DATE: 2/24/2014 <br /> PROPERTY/BUSINESS OWNERQ O-PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Compliance Officer <br /> If APPLICANT is not the BILIJNG PARTY proof of authorization to sign is required Title <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: U61-ST inspection % G!' <br /> COMMENTS: <br /> ACCEPTED BY: t`W EMPLOYEE#: /' DATE: / <br /> ASSIGNED TO: EMPLOYEE#: T� 6 DATE:a/ � <br /> Date Service Completed (if already completed): SERVICE CODE: P IE: Z3 <br /> Fee Amount: Amount Paid 37�Q(� Payment Date / <br /> Payment Type I -' Invoice# Check# 2— Aecelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />