Laserfiche WebLink
SAN JOAQU 'COUNTY ENVIRONMENTAL HEALTI" NEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />gas station <br />FACILITY ID # <br />-n -(X) 1 L$ <br />COMMENTS: <br />SERVICE REQUEST # <br />SizCEF —IoL� 10 <br />OWNER / OPERATOR <br />Jesus Jurado <br />CHECKff BILLING ADDRESBEl <br />CHECK If KILLING ADDRESS <br />FACILITY NAME Rancho San Miguel <br />PHONE# <br />�• <br />SITE ADDRESS 61V CherokeLane, <br />Stnet Number <br />Lo <br />D n <br />i <br />$Irelt NaMe <br />HOME or MAILING ADDRESS <br />city <br />F 41P C e <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Stmt Number <br />Invoice # Check # <br />SM.1, Na <br />CITY <br />CITY San Jose <br />STATE ZIP <br />PHONE Ni Eat' <br />( 1 <br />APN# <br />LAND USE APPLICATION# <br />PHONE 02 En' <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />- R y'SIUC <br />COMMENTS: <br />Marty Weithman <br />ACCEPTED BY: <br />CHECKff BILLING ADDRESBEl <br />BUSINESS NAME Service Station Systems, Inc. <br />DATE:© (9 <br />PHONE# <br />�• <br />DATE: " ( r' <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />Fee Amount: - <br />FAX# <br />Payment Date /Si <br />680 Quinn Ave <br />Invoice # Check # <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br />acknowledge that all site find/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 laws. <br />APPLICANT'SSIGNATURE:Tkuxt4, tc,�' 'tk t--k4cA4d--0--4-,U DATE: 2/10/2015 <br />PROPERTY/BUSINEssOWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT E) Compliance Officer <br />/fAPPLICINT is not the BILLNG 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. <br />TYPE OF SERVICE REQUESTED: UST inspection 'r1V-•�"t' <br />- R y'SIUC <br />COMMENTS: <br />J/E� FQ <br />4N;4r qi <br />Eyr <br />ACCEPTED BY: <br />EMPLOYEE III: <br />DATE:© (9 <br />ASSIGNED TO: �� ( L/ (( - <br />EMPLOYEE #: <br />DATE: " ( r' <br />Data Service Completed (If already Completed): <br />SERVICE CODE: <br />PI E. �3�g <br />7 D <br />Fee Amount: - <br />Amount Pai3qp. �� <br />Payment Date /Si <br />Payment Type <br />Invoice # Check # <br />ReDelved By: <br />EHD 45-02.025 SR FORM (Golden Roo) <br />REVISED 11/17/2003 <br />