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SAN JOAN COUNTY ENVIRONMENTAL HEALSEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station <br />CNECKIf8ILLINGADDRESSE1 <br />OWNER / OPERATOR <br />PHONE# <br />AT&T California <br />ASSIGNED TO: <br />CHECK IfBltuNGADDRESS® <br />FACILITY NAME AT&T (UG010) <br />213-6038 <br />HoMEorMAILiNGADDRESS <br />SITE ADDRESS 1812 Coley Ave <br />Escalon <br />A 95320 <br />—7—T <br />Fee Amount: <br />(408 <br />—".Coe <br />St et Number <br />nName <br />ZIP 95112 <br />Invoice # <br />city <br />Received By: <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Streat Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 EXT. APN 9 <br />( l <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />REC <br />Marty Weithman <br />CNECKIf8ILLINGADDRESSE1 <br />BUSINESS NAME Service Station Systems, Inc. <br />PHONE# <br />EXT. <br />ASSIGNED TO: <br />408 <br />213-6038 <br />HoMEorMAILiNGADDRESS <br />FAX# <br />680 Quinn Ave <br />Fee Amount: <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />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 I 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: TtL-t ('T-esti.(-/ ( I • �,? -e'4L tt-��1-� DATE: 4/7/2014 <br />PROPERTY / BUSINESS OWNERM OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT E] Compliance -Officer <br />IfAPPL/CANT 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. <br />DA .._ <br />TYPE OF SERVICE REQUEST _\ <br />UST inspection <br />REC <br />COMMENTS:SAN <br />APR U 9 2 <br />E JOAQUry OAJC <br />HPOLI <br />-44N DEPS �F <br />ACCEPTED BY:EMPwYeie <br />#: -3(1-1( <br />DATE: </ { q <br />I <br />ASSIGNED TO: <br />EMPLOYEE #: pC) U / <br />DATE: -L c// -/ <br />Date Service Completed (if already completed): <br />SERVICECODE: r S <br />P / E: Z368' <br />Fee Amount: <br />Amount Paid <br />375- 6DPayment <br />bate <br />g <br />Payment Type <br />Invoice # <br />Check # 43,os— <br />Received By: <br />EHD 48-02.025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />4 <br />