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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station6b-]q 959 <br /> OWNER iOPERATOR <br /> Boyette Petroleum CHECKIf1iILLlkoADDREss <br /> FACILITY NAME H&M Market (Kwik Serv) <br /> SITE ADDRESS 2501 Jackson e,Escalo CA 95320 ,rAV D <br /> Steel Number. pincyon [I SU"t NameZID Cafti <br /> HOME or MAILING ADDRESS (if Different from Site Address) AUG '� 1 2018 <br /> Street Number et N U <br /> CITY STATE ZIP <br /> PHONE 91 Etn• APN 0 LAkD USE NtAtTH <br /> ( ) ;L22-2-70 11 DEPARTMENT <br /> PHONE 82 Exr. BOS DISTRI LOCAmok CODE. <br /> I 1 F <br /> CONTRACTOR/SERVICE RE'QUESTOR <br /> REQUESTOR Marty Weithman CHECK ItSILLiNdADORESSO. <br /> BUSINESS NAME Service Station Systems,Inc. PHONE# Exr• <br /> y 408 1 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave Ful# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> _BILLING_ AMENT: 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 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: DATE-DATE- 8/1/2018 <br /> PROPERTY/BUSINESS OWNERD OPERATOR/MkNAGER OTI1FRAUT14ORIZEDAGEN7 E) Compliance Officer <br /> 1fAPPLICANT is.not the.BILUINQ PAR33L 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 ther <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 inspectionVJVAt11-- RECEIVED <br /> COMMENTS: <br /> AUG 012018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH pEpARTMENT <br /> ACCEPTED BY: nil 0-0 <br /> EMPLOYEE#: DATE: a <br /> ASSIGNED TO: iz 'LMPLOY.EE#: DATE: i f <br /> Date Service Completed (If already complet ): SERVICE CODE: `` PIE;31 <br /> ` < <br /> Fee Amount: ount Paid 6 Paynrent.Date <br /> Payment Type ;S�1 nvoice# Q I ? Received By: <br /> EHD 48-D2-025 SR FORM(Golden Rod) <br /> REVISED 11!17/2003 <br />