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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 i ��Y `/ G(% (<'4' 4- <br /> OWNER/OPERATOR CHECK If BILUNG ADDRESS <br /> Food 4 Less/Robert Silva <br /> FACILITY NAME Food 4 Less <br /> SITE ADDRESS 3408 Manthey Ild. Stockto CA 95206 F 7Z.C'0 <br /> Street Number n r Name city <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Err. APN* LAND USE APPLICATION# <br /> ( 1 <br /> PHDNE#2 En. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECKIfBILLINGADDRESS ] <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# EXT. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS FAx <br /> 680 Quinn Ave <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: 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 l 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: �uF t�t �' I til t—A tiL DATE: 2/19/2013 <br /> PROPERTY/BUSINESS OWNERD OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E) 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. <br /> TYPE OF SERVICE REQUESTED: UST inspection I ✓`t-T/%�i/=/ / RSC �T <br /> COMMENTS: �C+� <br /> CC <br /> � R 2013 <br /> �D P4feo�Nc�uMY <br /> ACCEPTED BY: lam" EMPLOYEE#: DATE: <br /> ASSIGNED TO: "Tf/'tr✓ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I c l P i E: <br /> Fee Amount: '3"���'� Amount PaidP3��,D-6 Payment Date 3 <br /> Payment Type Invoice# Check# d3 Recelved By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />