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SAN JOAQ000UNTY ENVIRONMENTAL IIEALT*EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station —� <br /> OWNER i OPERATOP1 <br /> J !J S�1 V< �` V/i,ry Cl CHECK If BILUNq AODRESSff <br /> FACILITY NAME Rancho San lMiguel Market(Food for Less) <br /> SITE ADDRES Airportay, Stoc ton CA 95206 <br /> $/tell Num Eu Dr ra Na e city ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Seed NumMr Stm.L NAMO <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPUCA71ON# <br /> PHONE#2 En' BOS DISTPoCT LOCATON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK)f BILLING ADgAESSE <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# Ext <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAz# <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 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 fomt. <br /> 1 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:r�i 1 t i ti,c,� ��'_�.idl_ L�-'A-t l-.. DATE: � I t � a:(S� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORMED AGENT[] Compliance Officer <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, r <br /> TYPE OF SERVICE REQUESTED: UST inspection S- �'%( �P7 <br /> COMMENTS: ` O FQ <br /> ACCEPTED BY: EMPLOYEE#: DATE: ('y'_ ':•— <br /> ASSIGNED TO: lw� , �/�4.t. I <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: ci�`� Pi E: <br /> Fee Amount: iL �1) Amount Pa 4y 376,b-�) Payment Date 7 <br /> Payment Type Invoice# Check# L 7 Recelved By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> I <br />