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SAN JO <br />Type of Business or Property <br />gas station <br />OWNER/ OPERATOR <br />Safeway Inc. <br />FACILITY NAME Safeway #2707 <br />SITE ADDRESS 6425 N Pacific ve. S <br />JIN COUNTY ENVIRONMENTAL HEAL,., DEPARTMENT <br />SERVICE REQUEST <br />FACILITY ID II SERVICE RED EST# I <br />Fgoo�2y-mss �!2(`�� 1�� <br />CA 95207 <br />HOME or MAILING ADDRESS (If Different from Slte Address) <br />CITY <br />PHONE#I In. APN# <br />( I <br />PHONE tit En. <br />CONTRACTOR/SERVICE <br />REOUESTOR <br />Marty Weithman <br />BUSINESS NAME Able Maintenance, Inc <br />HOME or MAILING ADDRESS <br />680 Quinn Ave <br />CITY San Jose <br />CHECK If BILLING ADDRESS C1 <br />STATE ZIP <br />LAND USE APPLICAnON# <br />BOS DISTRICT LOCATION CODE <br />2UESTOR <br />CHECK U BILLING ADORES! <br />T <br /># 213-6038) 213-6026 <br />STATE CA ZIP 95112 <br />BILLING ACKNOWLEDGEMENT: 1, 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 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: 171LttOL �,- ,Lcz L uL t —DATE: 2/24/2015 <br />PROPERTY/ BUSINESS OWNERO OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Officer <br />IfAPPL/CANT iS not the BILUNGPARTr proof of authorization to sign Is required Title <br />AUTHORIZATION TO REL AS )NFOAMATION: 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 PIY ` IN <br />COMMENTS: PA <br />ACCEPTED BY: <br />ASSIGNED To: '�E' ,A r—E L F <br />Date Service Completed (If already completed): <br />Fee Amount: 37CJD -O l7 Amount Paid <br />PaymentPayment 7'ypeAI,,,t� invoice #Invoice I <br />EHD 48.02-025 `--0 P <br />REVISED 11/17/2003 <br />F tB 2 4 2015 <br />SAN <br />EMPLOYEE #: <br />EMPLOYEE #: <br />SERVICE CODE: <br />`� Q , p (� Payment Date <br />Check # <br />4,41VIOMEiNTAL <br />TH DEPARTMENT <br />DATE: ? 2 14 - 117 <br />DATE: 2 _ 2-1F- I i' <br />PIE: <br />Received By: 7 p <br />SR FORM (Golden Rod) <br />