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t SAN JOAQ*COUNTY ENVIRONMENTAL HEALTFOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> gas station SECO 16)t?wl'z <br /> OWNER/OPERATOR <br /> Gilbert Silva CHECK If BILI.1Nt3ADDRESS <br /> FACILITY NAME Rancho San Miguel Market <br /> SITE AODr';" <br /> 7�W Airport ay <br /> Slero et Number n Street Name city ZIP Code <br /> HOME or MAILING ADDRESS (If Different from.Site Address) <br /> Street Numbor §096L Name <br /> CITY STATE ZIP <br /> PHONE#1 Ext. APIN# LAND USE APPLICATION# <br /> PHONE#2 Err• 805 D15TRICT I OCAT1oN CODE <br /> L r1� <br /> CON'T'RACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman <br /> CNeCx if tilulNti ADDRESS 0 <br /> BUSINESS NAME PHONE# Err• <br /> Service Station Systems, Inc. 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAx# <br /> {408 } 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKN W ED M NT: 1, 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 bone in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �t _t.� `' �_C �-t-ft.z i L_lt---t(i DATE: 7/1412014 <br /> PROPERTY IBusiNESSOWNER O OPERATOR/MANAGER❑ 0TNERAl1T1i0R2ZEDAGENTO Compliance Officer <br /> 1f APPLICANT is no1 the B1LL1NG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFQIBM,&TJON: 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 ��r p'P"`* NT <br /> COMMENTS: f f Iv },/ ❑ <br /> I <br /> �9"kdNi�IE <br /> NEAL t*6 <br /> ACCEPTED BY: 1 , EMPL{3YEE#: DATE: / i 7 /J <br /> ASSIGNED TO: i✓ EMPLOYEE#: DATE: t <br /> Date Service Completed (if already completed): SEMACECODE: lC�'�' PIE: -2-9 C <br /> Fee Amount: 3 ��G`' Amount Pal 3� ©� Payment Date <br /> Payment Type Invoice Check Ree Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />