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i <br /> WIN <br /> Aly JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> y , ' SERVICE REQUEST <br /> FACfI;IT1' 1D # SERVICE A %4%jE$T <br /> Type of balitemV PropertyINN <br /> mea skation � �ar <br /> Fpi�tt <br /> low <br /> OVJhItk l OPERATOR CHECK if &Ot A ADORassL.I ' <br /> � A <br /> saA <br /> FACILITY NAME Safeway #2600 111111 WIN "F <br /> SITE ADDRESS 1987 W 11th St Tracy CA 5376 <br /> air t u bu 7a Name C C' <br /> HOME or MAILING ADDRESS (it Ditferent from site Address) <br /> aUeetNumbar t e LNe <br /> STATE ZIP <br /> CITY <br /> Ext• APN # LANG USE APPLICATibN'# <br /> PHONE M <br /> t l <br /> PHONE #2 ExT. 605DI$Ti LocATIO <br /> NC.Obt <br /> ( ) <br /> CONTRACTOR. / SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECKIfAILLNoAaq= 0 <br /> PHONE# Exr, <br /> euslNEss NAME Service Station Systems, Inc, 408 213-6038 <br /> 1 11 Ill Ill Ill Home or MAILINo ADDRESS <br /> 680 Quinn Ave 14,0. . 408 ) 213-696 <br /> STATE CA 210 96112 <br /> CITY San Jose <br /> BILLING r� OKNOWL-EDG 'MENTI 11 the undersigned property or business owner, operator or authoA zed agent df same,. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT Hourly charges associated with this pill <br /> or activity will be billed to me or my business as identified on this form, <br /> 1 also certlfy 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 SIGNATUREI ( c�; t ,l,.� <br /> 1f J,1tA,�,t,i�t..tyl..+ DATE; 6!21 !!2019 <br /> PROPERTY / BUSINESSOWNEA❑ OPERA70RlMANAQER ❑ OTNERAl1THORlZEnAGENI a Compliance Officer <br /> If/1 PPLICANT is not the BILLINJ PARTY, proof of authorisation to sign is required TlrlE <br /> AUTHO IR 2AT1QN TO E IVA.Q INFORMATJ011 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 envlrommentallsite assessment <br /> E information to the SAN ]OAQll1N COUNTY ENVIRON <br /> MENTALPIEALTH DEPARTMENT as soon as it is available and at the sarne time. it is <br /> provided to me or my representative . <br /> i <br /> TYPE OF SMAGE REQUESTED, u ��ge}jetrr� Ort �J J�- G�1 r � <br /> COMMENTS: <br /> All <br /> �r � IV <br /> IF A <br /> ACCEPTED BY' EMPLOYEE #: /< DA E: ! 5 '? <br /> •� ' ✓ EMPLOYEE #: a0 �ANN 7 l ! <br /> DATE: <br /> ASSIGNED TO : <br /> Date Service Completed (If already eompietod) 3 <br /> SERWE.C.ODE: <br /> Fee Amount; y t Amount �Paid paymorif Dx(e <br /> Payment Typo <br /> Invoice # <br /> Chock <br /> # rj Received Sys <br /> 5R, FORM (Ooiden Rodj <br /> END 48.02.025 <br /> REVISED 11 /1712003 <br />