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SAN JOA,_iN COUNTY ENVIRONMENTAL HEALT,- DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station PHONE# 408 OWNER / OPERATOR CNECR Safeway Inc. It BILLING ADDRE99O FACILITY NAME Safeway CITY San Jose STATE CA ZIP 95112 SITE ADDRESS 6425 N Pacificve, Stock n CA 95207 ACCEPTED BY: 3 rt N.tm DATE: '2 Z ASSIGNED TO: S mi]angC N Zip Cod* HOME or MAILING ADDRESS (If Different from Site Address) 5918 Stoneridge Mall Rd SIMINYmMr wit CITY Pleasanton STATE CA Zip 94588 PHONE#1 En. 1 1 APN a Fee Amount: LAND USE APPLICATION a PROVE 02 En. 1 ) Payment Date BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR Marteman Y With CNECR If BILLING ADORESc❑✓ BUSINESS NAME Service Station Systems, Inc. PHONE# 408 Err. 213-6038 HOME or MAILING ADDRESS 680 Quinn Ave 7�4Z4N,�,,20p FA%# 1408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator Or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: l(c.-`C ` �. �6,t L c('t i DATE: 12/10/2012 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT +❑ Compliance Officer IfAPPLIcANT 1s not the BILLING PARTY proof of authorization to sign Is required TIAs AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPEOFSERVICE REQUESTED: UST inspection COMMENTS: 7�4Z4N,�,,20p ACCEPTED BY: EMPLOYEE #: DATE: '2 Z ASSIGNED TO: S EMPLOYEE #: DATE: Date Service Completed (N already completed): SERVICE CODE; Fee Amount: Amount Paid 3-16- Payment Date Payment Type Invoice # Check # 3 ! Recelved By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2DO3