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SAN JOAN,JIN COUNTY ENVIRONMENTAL HEALTri DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID 9 COMMENTS: SERVICE REQUEST A gas station O a I BUSINESS NAME Service Station Systems, Inc. `cc &S 7-6.2— OWNER / OPERATOR ET. CHECK If Safeway 408 fill -UNG ADDRESS FACILITY NAME Safeway DATE: FAzp 680 Quinn Ave PIE: 230Q SITE ADDRESS Amount Paid �` Payment Date 2 Payment Type (408 ) 213-6026 CITY San Jose 6425 N Pacificve Stockt n CA 95207 S rot 14—G' Ci 'ID Code HOME or MAILING ADDRESS (If Different from Site Address) SIrMI NYTL•I In•I CITY STATE ZIP PHONE III En. APN t) LAND USE APPLICATION a PHONE #2 En. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR COMMENTS: Marty Weithman CHECK It BILLING ADDRESS BUSINESS NAME Service Station Systems, Inc. SAN JOAQUIN COUNTY PHONE Ii ET. ACCEPTED BY: L-0 LL):&;7 EMPLOYEE M Cl OST 408 213-6038 HOME or MAILING ADDRESS DATE: FAzp 680 Quinn Ave PIE: 230Q Fee Amount:3 j Amount Paid �` Payment Date 2 Payment Type (408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, 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. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: fltn ,c.L« 1 �' /k -(-(t DATE• 9/11/2012 PROPERTY/BUSINESSOWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT E) Compliance Officer 1jAPPLiCANT is not the B/LUNo PmTY. proof of authorization to sign is required Title 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. TYPE OF SERVICE REQUESTED: UST inspection JAS 7" COMMENTS: ri L �, EIVED SEP 13 A.4, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: L-0 LL):&;7 EMPLOYEE M Cl OST DATE: y (3 1 Z ' )' ' ASSIGNED TO: �)�-vyv-{i't.L�J EMPLOYEE 6 "/J DATE: Date Service Completed (If already completed): SERNCECODE: ( Ole PIE: 230Q Fee Amount:3 j Amount Paid �` Payment Date 2 Payment Type I Invoice tl Check # 4 r Re Ived By: EHD 48.02-025 SR FORM (Golden Rod) REVISED 11/17/2003