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SAN JOAQ, -.d COUNTY ENVIRONMENTAL HEALTh _.sPARTMENT <br /> r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#` <br /> gas station oS�QC� 5',�pp//Zb IS <br /> OWNER/OPERATOR tC� <br /> Safeway Inc CHECK If yILL1NG A[IDRESSa <br /> FACILITY NAME Safeway <br /> SITE ADDRESS 6425 N Pacific Fye n CA 95207 <br /> Sinal NumGr ro d <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3918 Stoneridge <br /> SM�1 NYTIMr lrnl N� <br /> CITY Pleasanton STATE CA ZIP <br /> PHONE 01 an. APN a LAND USE APPLICATION tl <br /> ( 925-467-2707 <br /> PHONE 02 SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Wei[hman CHECK If BILLING ADORES <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# Er. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAT# <br /> (408 ) 213-6026 <br /> CIT' San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: I, 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: It(CLL rl LL � �)L ,� t-'43- -L GL-M L1 DATE: 6/20/2011 <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT +❑ Compliance Officer <br /> 1jAPruaNr is not the B/LLNG PA)? proof of authorization to sign is required rinr <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 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 ENT <br /> COMMENTS: �r CN <br /> )U1`1 2 � 2ouNn <br /> SW'tEN�RONMEtdTWNT <br /> Eli-N Dep R <br /> H <br /> ACCEPTED BY: (�L(',l)C EMPLOYEEM CTC, DATE: ZI <br /> ASSIGNED TO: Rc(LLIS EMPLOYEE#: 31c> DATE: & Zi JI <br /> Date Service Completed (if already Completed): SERVICE CODE: L PIE: r) <br /> Fee Amount: ���� Amount Paid '3 bio _ Payment Date (p 12-1/ 1 <br /> Payment Type ./ Invoice# Check# 3 s 7 Recelved By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />