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SAN JOAa COUNTY ENVIRONMENTAL HEALT, EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station �0q S2,1-o(c39C <br /> OWNER/OPERATOR <br /> Stan Olea CHECK I}BILUNO ADDRESS� <br /> FACILITY NAME Safeway <br /> SITE ADDRESS 6425 N Pacificve Stockt n CA 95207 <br /> n <br /> S M NumlWl CI <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Stml Num W r tnN No <br /> CITY STATE 2AP <br /> PHONE#I E", APN R LAND USE APPUCATION I( ) <br /> 4 <br /> PHONE12 E". SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK It BILLING ADDRESS <br /> BUSINESS NAME Able Maintenance, Inc PHONES E". <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: 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 andFEDERALlaws. <br /> APPLICANT'S SIGNATURE: �9{ (S LLLC''L 6" Aa -' LLQ- L-1' DATE: 11/17/2011 <br /> PROPERTY/BUsINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Officer <br /> lfAPPWGNT is not the BILLING PARTY.proof of authorization to sign is required Titre <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: UST inspection QST7PAVURINIT <br /> — <br /> COMMENTS: RECEIVED <br /> NOV 18 2011 <br /> SAN JOAQUN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTLENr <br /> ACCEPTED BY: Cx E EMPLOYEE M g clJ 2 DATE: f/ L // <br /> ASSIGNED TO: _ C1. lS EMPLOYEE#: b� DATE: // / !� <br /> Date Service Completed (N already completed): SERVICE CODE: IqJ P �T <br /> Fee Amount: �7�0c' Amount Paid 3�(� o-0 Payment Date It � l <br /> Payment Type Ciy Invoice# Cheek# 2J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />