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SAN JOAQI"N COUNTY ENVIRONMENTAL HEALTF' T)EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST k <br />gas station <br />di o Cl <br />BUSINEss NAME <br />S <br />OWNER / OPERATOR <br />ax,. <br />Misty Cook <br />CHECK It BILUNG ADDRESS❑ <br />FACILITY NAME Safeway #2707 <br />213-6038 <br />SITEADDRESS 6425 N Pacificve, <br />Stock n CA 95207 <br />FAX# <br />ASSIGNEDTO:EMPLOYEE#: <br />680 Quinn Ave <br />Stroll Num Gr <br />e <br />) 213-6026 <br />CIN <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount: <br />Amount Pa <br />Stroel Num W r <br />Payment Date /S' <br />roel Nem <br />CITY <br />STATE ZIP <br />PHONE #t En. <br />APN # <br />LAND USE APPLICATION # <br />I 1 <br />oq�� 1b31 <br />PHONE 02 an. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Marty Weithman <br />COMMENTS: P <br />RECENED <br />APR 23 <br />CHECK It BILLING ADDRESS <br />BUSINEss NAME <br />� APR 2 3 2015 <br />PHONE# <br />ax,. <br />Service Station Systems, Inc. <br />HEALTH DEPARTMENT <br />408 <br />213-6038 <br />HOME Or MAILING ADDRESS <br />EMPLOYEE M <br />FAX# <br />ASSIGNEDTO:EMPLOYEE#: <br />680 Quinn Ave <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 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 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'S SIGNATURE: e-t� ( V • DATE: 4/21/2015 <br />PROPERTY/ BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHERAuTNORIZEDAGENT +❑ Compliance Officer <br />I,fAPPL/01NT is not the BILGNG PARTY proof of authorization to sign is required Titre <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: USTinspection r-eA-tp(-tl <br />COMMENTS: P <br />RECENED <br />APR 23 <br />2015 <br />� APR 2 3 2015 <br />Efvv1RON <br />S"ENVIRONMENTALry <br />p�Qnn SE9Vi s tat, <br />HEALTH DEPARTMENT <br />ACCEPTED BY: -' kid <br />EMPLOYEE M <br />DATE: -a3-1 <br />ASSIGNEDTO:EMPLOYEE#: <br />DATE: oZJ_/i <br />Date Service Completed (If already completed): <br />SERVICE CODE: )�.- <br />PIE: <br />e <br />Fee Amount: <br />Amount Pa <br />3 ld.6 <br />Payment Date /S' <br />Payment Type <br />Invoice # <br />Check* S! 3 <br />Received By: <br />END 48.02.025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />