Laserfiche WebLink
SAN JOAQuIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID N SERVICE REQUEST II <br /> gas station 4 pq <br /> Sr2oo,S�G,�;Z <br /> OWNER/OPERATOR <br /> Safeway(Stan Olea) CHECK If BIWNG ADDRESS❑ <br /> FACILITY NAME Safeway <br /> SITE ADDRESS 6425 N. Pacificve,Stoc on CA 95207 <br /> Mean mober <br /> HOME or MAIUND ADDRESS (If Different from Sita Address) 5918 Stoneridge Mall Rd <br /> SUntNumber Inst <br /> CITY Pleasanton STATE CA ZIP 94588 <br /> PHONE S1 En, APN It LAND USE APPLICATION If <br /> ( ) D 17-4(0.31 <br /> PNDNEI'2 En. BOS DISTRICT LOCATI 2— CODE <br /> I ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR MartWeithman ✓❑ <br /> Y CHECK H BILLING ADDRESS <br /> BUSINESS NAME Able Maintenance, Inc 1408 Er. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAX R <br /> (408 ) 213-6026 <br /> Cin' 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 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: 1/14&Xrkl j, (), DATE: 3/24/10 <br /> PROPERTY/BUSINESS OWNERG OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENTr❑ Compliance Offier <br /> 1f,4PPL1C4Nr is not the B/LLING 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. nn � r <br /> TYPE OFSERVICE REQUESTED: UST Inspection (.LST/—c i "F ENT <br /> COMMENTS: RECE <br /> MAR 25 2010 <br /> 1RONME TWT EN <br /> DEPAR <br /> ACCEPTED BY: 40 L t V et se�+ EMPLOYEE#: 0 3 L/ DATE: ZS to <br /> ASSIGNED To: fEGI�iLf.._f EMPLOYEE#: DATE: 3 2S f <br /> Date Service Completed (N already completed): SERVICE CODE: ctg PIE; <br /> Fee Amount: S 6rD Amount Paid 3y S _ Payment Date 312-S 10 <br /> Payment Type / Invoice III Cheek# 2 27 y Received By: ,— <br /> EHD 48-D2-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />