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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYRV1C <br /> ID EE. REQUEST # <br /> gas station 3 0 t,S , o 1 <br /> OWNER:I OPERATOR <br /> Boyette Petroleum GHECKff BILUNG 'ADORESSI.e,t <br /> FACILITY NAME H & M Market (Kwik Serv) <br /> SITE ADDRESS 2501 Jacksone , Escalo CA 95320 <br /> 9lnet Number Strool NamoCIZip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> SlrealNumber StreatName <br /> CITY STATE ZIP <br /> PHONEgi Em APILAND Use APPuCATI6N4 <br /> PHONE #T EM• BOS DISTRICT LocAT100 CODE. <br /> ( i <br /> CONTRACTOR / SERVICE REQ UESTOR <br /> REQUESTOR Marty Weithman CHECK.I( BILLINGADDRESSM <br /> IF <br /> BUSINESS NAME Service Station Systems , Inc. PNONE # <br /> 408 213-6038 <br /> HOME or MAILINo ADDRESS 680 Quinn Ave Fax # <br /> (408 ) 213 =6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized aget)t; of seine,. <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 idendfied on this form. <br /> 1 also certify that 1 have prepared this application and that the work to be. perf6rme.d will be done in . accordanee with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standarrds, STATE and FEDERA1. laws . C� 1 <br /> APPLICANT' S SIGNATURE: GG� ¢c,( �.w U . ivu-+ c-�- t.� DATE* ; <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER LJ 0THERAUTHORiz9oAGENT0Compliance Officer <br /> IfAPPLICANT is not the BILUMOT-A,R proof of aufhorizgtion to sign is required Tirlc <br /> AUTHOR] AZ TION 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 environirlentetJsite . yiei(l <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it available and at the s tit <br /> provided to me or my representative , C �'► <br /> TYPE OF SERVICE REQUESTwt UST inspection <br /> COMMENTS: S,qN <br /> &441 oNINOO 19 <br /> MF T <br /> ACCEPTED BY: S1 , �v EMPLOYEE #: QATF: C/ ICS / <br /> gq <br /> AssioNED 70 : CJ L� 'EMPLOYEE #; O DATE' VH <br /> Date Service Completed (If already compiette!) tj JSENdIFOODE'IMe P I B :� / Q <br /> Fee Amount: sJ� V d Amount Patd �U Payment Date jd o <br /> Payment Type Invoice # Check # S 13eeoi ed' By : <br /> EHD 48-02-025 SR+0RM (Golder) Rod) <br /> REVISED 11 /17/2003 <br /> IIS <br />