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SAN JQAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> gas station � R OOS Iq�O <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADORES$ <br /> Speedway <br /> FACILITY NAME Speedway <br /> SITE ADDRESS 401 W Kettlema Lane , L i CA 95240 <br /> Street Number $1rept Name Zip Code' <br /> HOME or MAILING ADDRESS (I (Different from Slte. Address) <br /> Street Number treelNn e <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 1 0 L 501 a1 <br /> PHONE #2 EXT. BOS DISTRICT � �� LoCATION CODE. <br /> ( ) U2 <br /> CONTRACTOR / SERVICE REQ_VESTOR <br /> REQUESTOR Marty Weithman CHECK If BILL1NGADOREss ✓0 <br /> BUSINESS NAME PHONE # EXT' <br /> Service Station Systems , Inc . 408. 213 -6038 <br /> HOME or MAILING ADDRESS FAX' # <br /> 680 Quinn Ave (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGE 1 , the undersigned property or business owner, operator .or authorized agent of ame, <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 l 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 JaWs . <br /> �+ � i El , <br /> APPLICANT' S SIGNATUR <br /> y,E : �(��t't'' l.�tit.� DATE: 2/14/2020 <br /> PROPERTY / BUSINESS OWNERO OPERATOR / MANAGER ❑ OTnERAUTHORIZEDAGMT ✓0 Compliance Officer <br /> IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Talc <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, I , 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 /> LL <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as if iS available and at. the same time it is <br /> provided to me or my representative , Avan <br /> TYPE OF SERVICE REQUESTED : UST inspection REV1 Er <br /> COMMENTS: FEB 2 42010 FEB 18 2020 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> HEALTHDEPARTMENT PERMIT/ SERVICES <br /> ACCEPTED BY: C `/ EMPLOYEE #: DATE: a� <br /> ASSIGNED TO : EMPLOYEE #, DATE: fZ C ,z <br /> Date Service Completed (if already completed) : SEevlceCotiE; (' P I Er� <br /> Fee Amount: G� Amount Pal / .Sco. (Xj -� j � 1S Payment Date Z 2� ?�D <br /> Payment Type �► Invoice # Check # S�j� Recelved By : <br /> EHDREV SED 11 /1 SR FORM (Golden Rod} <br /> REVISED 11117/2003 lak J� �? � � jp <br />