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SAN JOAQ, COUNTY ENVIRONMENTAL HEALTH PARTMENT �Z <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> gas station ylzu, � 1-<c)k-C67'510q <br /> OWNER/OPERATOR <br /> Dealer(MAyra Rupi) CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Waterloo Shell#136143 <br /> SITE ADDRESS 4315 E Waterlo Rd, Stoc ton CA 95215 <br /> Street Number roName C I <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Straat Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPUCATION# <br /> ( 1 b'6 � <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR MartyWeithman CHECK If BILLING ADDRESS <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# EXT. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave Fax# <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 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: t-t—t I . i t.i ; 1.t �. t t L- DATE: 6/21/2016 <br /> PROPERTY/BUSINESS OWNER Q OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ✓� Compliance Officer <br /> If APPLICANT 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. p <br /> TYPE OF SERVICE REQUESTED: UST inspection RFC NT <br /> COMMENTS: N <br /> H �''114%� Zoos <br /> ACCEPTED BY: , EMPLOYEE#: DATE: / <br /> ASSIGNED TO: Zckf--e_P_ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P I E: <br /> Fee Amount: C c'C' Amount Pad ��b �� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />