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SAN JOA.,oIN COUNTY ENVIRONMENTAL$EALTt.A)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST/ <br /> gas station t f4 <br /> W / 0= <br /> OWNER/OPERATOR Safeway Inc. CHECK ff <br /> BILLING At1oRaSsc <br /> FACILITY NAME Safeway <br /> SREADDREss 6425 N. Pacific ve Stock n CA 95207 <br /> St.0t N.1w, n n <br /> Si N� city 'in Cod- <br /> HOME or MAILING ADDRESS (If Different from Site Address) 5918 Stoneridge Blvd <br /> Strnl NYmMr a . <br /> CITY Pleasanton STATE CA Zip <br /> PHONED En' APN11LAND USE APPLICATIONS <br /> ( 2539968700 ���- 1{f 0 3� <br /> PNONE82 1303 DISTRICT -2 LOCAaeN�.'WE <br /> ( ) C 7 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If RU NIA22RE55NE <br /> ❑✓ <br /> BUSINESS NAME Service Station Systems, Inc. 140841213-6038 4081 <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 660 Quinn Ave FAx# <br /> (408 ) 213-6026 <br /> CIT' 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: DATE: 6/17/2010 <br /> PROPERTY/BUSINESS OWNERD OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT Compliance Officer <br /> IfAPPLICANT is not the BILLING PAR7Y.proof of authorization to sign Is required Titl, <br /> AUTHORIZATION 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 resuhs, 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. S- -- F / 7— <br /> TYPE <br /> TYPE OF SERVICE REQUESTED:UST inspection 1 /� <br /> COMMENTS: <br /> (n'L <br /> JUN 2 2 2010 <br /> ENVIRONRIENT NEA!TH <br /> PERMIT/SERVICES <br /> ACCEPTED BY: OC,f V E i P� EMPLOYEE M d3 L/ DAZEM�By: <br /> ASSIGNED TO: At-crr a c EMPLOYEE if: 7 CP,3/0 DATE <br /> Date Service Completed (N already completed): SEmnDECosE: ct Fee Amount: 3�S• Amount Paid 34 Payment Date LPayment Type Invoice V Check tY 2 Rec <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />