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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 � rl�2l� O) G <br /> OWNER / OPERATOR (•' 0 rU <br /> Aldo Basurto ( Safeway/Albertsons ) CHECK IT BILLING ADDRESS ❑ <br /> FACILITY NAME Safeway #2707 <br /> SITE ADDRESS 6425 N Pacificve <br /> Sleet Number Direction reName C <br /> HOME or MAILING ADDRESS (If Different from Site Address) R T <br /> Street Number treetName - ` � 1 'Nh• <br /> CITY STATE zip L / <br /> PHONE M ExT. API # LAND USE APPLICATION # 2023 <br /> ( ) SAN �OgQU J <br /> PHONE #2 EXT• BOS DISTRICT L QT� E (DU Ty <br /> ( ) PAR MENT <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If DILLI ADDRESS <br /> BUSINESS NAME Service Station Systems , Inc . PHONE # EXT• <br /> 408 1 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAx # <br /> (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 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 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 <br /> I Ws�, <br /> APPLICANT ' S SIGNATURE : T/tCxQxt.-"� " DATE: 1 /23/2023 <br /> PROPERTY / BUSINESS OWNER Q OPERATOR / MANAGER OTHERAUTHORIZED AGENT ✓❑ Compliance Officer <br /> IfAPPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE IN OBMATION : 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 . <br /> TYPE OF SERVICE REQUESTED : U ft in / % L <br /> COMMENTS: � <br /> ( r <br /> JAN 2 5 2023 <br /> I< NVIRONMENTAI_ HEALTH <br /> ACCEPTED BY: �% L EMPLOYEE #: DATE: 2� <br /> w � . y < - /Ago <br /> ASSIGNED TO : ''; ` l G � { �L 1 EMPLOYEE #: DATE. 0 '12 <br /> Date Service Completed (if already completed ) : SERVICE CODE : ;d - CJS <br /> Fee Amount: Amount Paid, ()d Payment Date 21112 <br /> 6k -117 <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02.025 SR FORM (Golden Rod) <br /> REVISED 11117/2003 <br />