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i <br /> i <br /> 6 <br /> SAN JOAQU COUNT NVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property I ACILRY td# SERVICE REQUEST# <br /> i <br /> gas station P <br /> OWNER/'OpERATOR Ckeck if @a UNO ADDRESS® <br /> Boyette Petroleum <br /> FACILITY NAME H&M Market (Kwik Serv) <br /> SITE ADDRESS 2501 Jackson Ave,Escalo I CA 95320 - <br /> Street Number tion em <br /> NOME or MAILING ADDRESS (if Different from Site Address) U G 1; 2 01 <br /> Street Number reel Ne <br /> STATE ZIP <br /> CITY <br /> LANb USE - <br /> PHONE#I EIn• APN# DEPARTMENT <br /> ( 1 <br /> X7-2_70 1 <br /> PHONE#2 Exr. hos DISTRICT LOCA710Nf.ODE. <br /> i l V 6 <br /> CONTRAC'T'OR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weititman CHEcxItaiLUNGADORESS0. <br /> BUSINESS NAME Service Station Systems,Inc. t.408 I 213-6038 <br /> HOME or MAILING ADDRESS 4p A <br /> 680 Quinn Ave (408 l 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BI LINg ACKNUWLEDGEIVIENT: 1,the undersigned property or business owner, operator or authorized Agent of saiue, <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`thet.the work to beTerforined will,be done in accordance with:all SAN-70;AQ11IN <br /> CouNTY Ordinance Codes,Standards,STATE and.FEDEM laws. <br /> APPLICANT'S•SIGNATURE: �:G(et,c �-+�V•. r"rp--�� DATE: 8/112018 <br /> PROPERTY/BUsmzssOWNERC OPERATOR/MANAGER I__I O.THERAUTHORIZEDA,GENTE) Compliance Officer <br /> JfAPPLICANT is.not the.BILLiffa PAR3Y proof of authorization to sign is required. rifle. <br /> j)TInRIZATIOi TO RF7C EASE INRORMATION:When applicable,1,the owner or operator of the property locatt:d:ai tKe <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environtnenteUsite.assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMINTAL HEALTH DEPARTMENT as soon as it IS available and at the same time it <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:UST Inspection RECEIVED <br /> COMMENTS: AUG 012018 <br /> -SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTEO BY: EMPLOYEE#: DOE:(CA Y1 . <br /> AS91t3NEO70: _ MPLESYEE#; DATE: t I. 1 <br /> tl <br /> Date Service Completed (If alreaFIE: <br /> campltaf ): SERV16t CODE: (` E: ` <br /> Fee Amount: mount Paid l Psyment.Date <br /> Payment Type ®� hvoice# !+h ' °77 'IrBy: <br /> SR:FORM(Golden Rod) <br /> EHD 48-02.025 <br /> REVISED 11/1712003 <br />