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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 station M000 ��'�7 00 <br /> OWNER / OPERATOR <br /> Boyette Petroleum CHECK If BILLING ApDRESS <br /> FACILITY NAME Kwik Sery Lodi <br /> SITE ADDRESS 420 W Kettlema Lane , L i CA 95240 <br /> Street Number Diroction $ Iraqi Nome CI e <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number StreetNaMg <br /> CITY STATE zip <br /> PHONE #t Em APN # LAND USE APPLICATION # <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK IfBILLING ADDRESS <br /> � <br /> BUSINESS NAME PHONE # EXT. <br /> Service Station Systems , Inc . 408 1 213-6038 <br /> HOME or MAILING ADDRESS FAx # <br /> 680 Quinn Ave <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: 1 , the undersigned property or business owner, operator or authorized agent of some, <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 laws . <br /> APPLICANT' S SIGNATURE : f4 "5 tip' �1 ' otC.644L .I DATE: 10/9/2019 <br /> PROPERTY / DUSINESSOWNERO OPERATOR / MANAGER ❑ OTHER AUTHORIzEDAGENT ✓❑ 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, 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 e assessment <br /> I to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t1 me it is <br /> provided to me or my representative . ` 0Y 11�'' Ipw <br /> TYPE OF SERVICE REQUESTED : UST inspection < ell A P� . V� <br /> COMMENTS: IVUV SgN ✓O O 2019 <br /> HEq Ty it IMF TAS <br /> '9RTtijFNT <br /> ACCEPTED BY: �� EMPLOYEE #: DATE: <br /> ASSIGNED TO : �(f EMPLOYEE #: DATE: MZ/ <br /> Date Service Completed (If already complete SERVICE CODE : 1Jq PIE4� <br /> Fee Amount* �yr Amount Pa Z14c-/ , v Payment Date � ( / <br /> Payment Type Invoice # Check # Zl Rece ved By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />