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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> New Gasoline Dispensing Facility and Market <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Safeway Inc. <br /> FACILITY NAME <br /> Safeway 0055 Fuel <br /> SITE ADDRESS 19533 South Mountain House Parkway Mountain House 95391 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 5918 Stoneridge Mall Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Pleasanton CA 94588 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925)226-5754 254-550-30 PA-1900293 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR WP�� C��� <br /> J l CHECK if BILLING ADDRESS <br /> BUSINESS NAME Oq PHO E# t EXT' <br /> HOME or MAILING ADDRESS �� FAX# <br /> CITY � �E /l STATE/? /J ZIP q,1, <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 'f'/ ._ DATE: June 6,2021 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT[@ Architect Contracted by Owner <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: Underground Storage Tank Installation RE /V T <br /> COMMENTS: uN 09 CJ <br /> � <br /> SAN jo 2421 <br /> NEA TN p PAENo UNTy <br /> I RTME <br /> N 4 <br /> ACCEPTED BY: ftm V EMPLOYEE M DATE: ri / f <br /> ASSIGNED TO: (�n �j S`A G EMPLOYEE#: DATE: IP/tJ� i�1 <br /> Date Service Completed (if already completed): ^ SERVICE CODE: 1 -31 P I E: �3 <br /> Fee Amount: (�.® "� Amount Paid 30 6)0Payment Date A <br /> Payment Type Invoice# Check# /Z�SZ-�o��' Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />