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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 LFAoolLfq go 0 S iPeat 1 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Food 4 Less <br /> FACILITY NAME Rancho San Miguel Market <br /> SITE ADDRESS 1427 S Airport ay, <br /> Street Number D n Stroot Name city Zie <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number StreatNamo <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR Marty Weithman CHECKIf BILLINGADDRESSM <br /> BUSINESS NAME PHONE # EXT' <br /> Service Station Systems , Inc. 408 213-6038 <br /> HOME Or MAILING ADDRESS FAX # <br /> 680 Quinn Ave (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 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 SIGNATURR,,E : l Cog ��,t , V . �1U c Q i _.f tt_ � V DATE: 9/ 10/2019 <br /> PROPERTY / BUSINESS OWNERII OPERATOR / MANAGER ❑ OTHERAUTHORIzFnAGENT ✓Q Compliance Officer <br /> IfAPPLICANT iS not the BILLING PARTY, proof of authorization to sign is required Title <br /> AOTHORIZATION 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 assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same a It is <br /> provided to me or my representative , y° <br /> TYPE OF SERVICE REQUESTED: U �tiop J / Ck pPA <br /> COMMENTS: OCTd <br /> /- ° z Za19 <br /> SAN N�AQUIN C <br /> EACT�p <br /> N MFA/ A N7y <br /> N <br /> EPq>^i T FNT <br /> ACCEPTED BY: ✓ �J EMPLOYEE # : DATE: <br /> ASSIGNED TO : S EMPLOYEE #: � � DATE: �a / <br /> Date Service Completed (If already completed ) : SERVICECODE ; P '/ Es <br /> OF <br /> Fee Amount; Amount Pal Payment Date Z <br /> Payment Type Invoice # Check # 1 Recel ed By : ELI <br /> EHD 48-02.025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />