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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 Y 0 S � ? vJ) <br /> OWNER / OPERATOR <br /> Boyette Petroleum CHECK if BILLING ApDRESS <br /> FACILITY NAME H & M Market ( Kwik Serv) <br /> SITE ADDRESS 2501 Jacksone , Escalo CA 95320 <br /> Street Number nONE $trept Name C �Zlnc�40— <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number StreetName <br /> CITY STATE zip <br /> PHONE # t E )m APN # LAND USE APPLICATION # <br /> ( 1 <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If BILLINGADDRESSr] <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: I , 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 . j <br /> APPLICANT' S SIGNATURE : IrI� p,I�C1,v � . ��! J DATE: / ( S / I rl <br /> PROPERTY IBUMNESSOWNERQ OPERATOR / MANAGER OTHERAl1THOR1zEDAGENT Q Compliance Officer <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Titte <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 atthe same time it is <br /> provided to me or my representative , ?� (,�nYc <br /> TYPE OF SERVICE REQUESTED : UST inspection / 6sC <br /> COMMENTS: J(/ <br /> SAN .jo , 4 ?019 <br /> FN QUI <br /> rAt <br /> v1 A <br /> ENT <br /> ACCEPTED BY : lJ V�� EMPLOYEE #: / � DATE: � /NR"JI 'REFAI� <br /> ASSIGNED TO : Z , ����� EMPLOYEE #: �J,�j DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE: �' PIEi2 <br /> Fee Amount: ae' Amount Paid . LAO Payment Date O <br /> Payment Type �7 1.00 Invoice # Check # S Rec ved By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />