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SAN JOa.&— COUNTY ]ENVIRONMENTAL HEALAEPARTMENT <br />MZ03239M <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST N <br />gas station <br />BUSINESS NAME Service Station Systems, Inc. <br />OWNER /OPERATOR <br />PHONE # <br />(408 <br />AT&T California <br />CHECK If §&LiNa A22Rzor! <br />FACILITY NAME AT&T (LIGO 10) <br />FAX# <br />(408 <br />SITE ADDRESS1812 Coley Ave <br />-:scalonA <br />I <br />95320 <br />ZIP 95112 <br />Payment Type <br />Invoice # <br />=heck # =Received <br />Qirggilon <br />ClIx <br />Z12 Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />strost Number <br />Street Njml <br />CITY <br />STATE zip <br />PHONE #1 Ext. APN I <br />LAND USE APPLICATION <br />PHowE#2 <br />SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUIESTOR Marty Weithman <br />COMMENTS: <br />CHECK If IIUJN2 ADDREA1 El <br />BUSINESS NAME Service Station Systems, Inc. <br />DATE: <br />PHONE # <br />(408 <br />EXT. <br />213-6038 <br />HOME or MAILINo ADDRESS 680 Quinn Ave <br />Date Service Completed (if already completed): <br />FAX# <br />(408 <br />213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />LLINf, ArHN"W EDGEMFdNT: 1, the undersigned property or business owner, operator or authorized agent of saint, <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: & u DATE; 4/7/2014 <br />PROPERTY/ BusyNiess OWNUD OPERATOR/ MANAGER 0 OTHER AtiTHORIZED AGENT E] Compliance Officer <br />JfA PPLICANT is not the Bwffia j:9RTY. proof of authorization to sign Is required Title <br />ZA]3Qt1 10 RELEASE 1D1FgMATJQ_N: 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 />TYPE OF SERVICE REQUESTED: LIST inspection <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE M, <br />DATE: <br />AssiaNet) To: <br />EMPLOYEE #C <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />I Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />=heck # =Received <br />By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />