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r I SAN JOAQ COUNTY ENVIRONMENTAL HEALTP EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station t,i`l C�-D.-+ <br /> OWNER/OPERATOR 1 <br /> Gilbert Silva CHI cKIfB&uxoApDREss1: <br /> FACILITY NAME Rancho San Miguel Market(Food for Less) <br /> SITE ADDRESS1499 S.Airport ay, Stoc ton CA 95206 <br /> Street Number d lr Name CI <br /> ty TZjPcRg2 <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Strae!Number nal Na <br /> CITY STATE zip <br /> PHONE#1 ExT• APN S LAND USE APPLICATION 11 <br /> ( ► I <br /> PHONE 02 Err. BOS DISTRICT LOCATION CODE <br /> ( I CJ 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Rl=Qtt ESTOR <br /> Marty Weithman CHE'CXIf I31LLINGA2DRE5SO <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# En. <br /> 408 213-6038 <br /> HOME or MAILINci ADDRESs 680 Quinn Ave FAX# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING CKN WLED M N : 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 /> 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;�L���� , j- '�. 'J It,_ ��- "— ,1.�.I- t t_ DATE: 5/29/2015 <br /> PROPERTY/BUSINESS OWNERD OPERATOR!MANAGER❑ OTHER AUTIIoRiEED AGENT[) Compliance Officer <br /> 1fAPPLIGINT is not the BILLING„&R7Y,Proof of authorization to sign Is required rille <br /> A,QTHORIZATION TO RELEASE INFOMATION: 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 erlvironmental/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 1 RFC MFN <br /> COMMENTS: /� 0 <br /> o � <br /> Ilk <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): i5 15 SERVICE CODE: P I E: Z <br /> Fee Amount: -DC C0 mount Pai 3'q(� JJ Payment Date J <br /> Payment Type Invoice# Check# / Received By: <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />