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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 ���� � <br /> OWNER/OPERATOR <br /> Speedway CHECK It BILLING ADDRESS <br /> FACILITY NAME Speedway <br /> SITE ADDRESS 2500 W Lodi, L di 95242 <br /> Street Numlxr n I StreetName city ZipCode <br /> FHoMEMAILING ADDRESS (if Different from Site Address) SVeal Number Creel Na STATE ZIP <br /> EXT. APN 701 LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS D1tTRICT LOCATION CODE <br /> ( ) / <br /> CONTRACTOR SERE STOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Systems, Inc. 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn AveFan# <br /> (\ LJZ (408 ) 213-6026 <br /> CITY San Jose STATE CA Zip 95112 <br /> BILLING ACKNOWLEDGEMENT: 1, the under ned roperty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific RO ENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my busin s gs i en ' led on this form. <br /> I also certify that 1 have prepared this applicaon d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: til Ll— 1�'. �,F�t 1 DATE: 6/24/20 <br /> PROPERTY/BUSINESS OWNER❑ O RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Q Compliance Officer <br /> If APPLICANT is not th BILLING PARTY proof of authorization to sign is required Title <br /> A HO ATI N IN AT N: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby a crize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQ N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my rept entative. 1 <br /> TYPE OF SERVICE REQUES D: S 7 <br /> COMMENTS: <br /> ACeEPTED BY: EMPLOYEE#: DATE: 2-2 <br /> ASSIGNED TO: EMPLOYEE M DATE: 2Q 1� <br /> Date Service Completed (if already completed): SERVICE CODE: PIE_ a <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />