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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> gas station Fife 06p� 40010 Sv� ODS 196( q <br /> OWNER / OPERATOR <br /> CHECK It BILLING ADDRESS <br /> Speedway <br /> FACILITY NAME Speedway <br /> SITE ADDRESS 401 W Kettlema Lane , L i CA 95240 <br /> Street N Strayt tlame city I <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberStreet Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LANE) USE APPLICATION # <br /> c ) 5 <br /> 01 el <br /> PHONE #2 Exr. BOS DISTRICT LOCAT10N CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR MartyWeithman CHECK IfBILLING ADDRESS <br /> � <br /> BUSINESS NAME PHONE # EXT. <br /> Service Station Systems , Inc . 408 213-6038 <br /> HOME Or MAILING ADDRESS FAX # <br /> 680 Quinn Ave (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 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 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 FEDERAL laws , � <br /> APPLICANT ' S SIGNATURE : ��( rs, � t . t '� U '/ L.�t {c ,tT ( i -�: DATE: 3/12/2020 <br /> II�� <br /> PROPERTY / BUSINESS OWNERII OPERATOR / MANAGER OT13ERAUTHORIZEDAGENT ❑✓ Compliance Officer <br /> 1fAPPL1CANT is no! the B1LLING 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 . c <br /> TYPE OF SERVICE REQUESTED : ee}icm UX7�9ie�17 W At wr <br /> F <br /> COMMENTS: +CD <br /> A <br /> R <br /> 0 <br /> AN '10420 <br /> HFA TH o NM�NoUTAt <br /> FpgR AL <br /> ACCEPTED BY: S. <br /> EMPLOYEE #: DATE: /{ „ <br /> ASSIGNED TO : ��h ��/f vl ,� EMPLOYEE #V DATE <br /> Date Service Completed (if already completed) , SERVICE CODE : 90 PiE : 2:; <br /> Fee Amount: 50 J Amount PaELS O Q Payment Date <br /> Payment Type Invoice # Check # Recel ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />