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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE R1 QUEST # <br /> gas station <br /> OWNER I OPERATOR CHECK if t31LQko ADDRES$ iri <br /> Corral Hallow <br /> FACILITY NAME Safeway #2600 <br /> SITE ADDRESS 1987 W 11th St Tracy CA 95376 <br /> Street NumberDir-actionre Name &P Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Stfeet Nutrl6er !reel Na <br /> CITY STATE ZIP <br /> PHONE #1 EkT. APN '# LAND USEAPPIdCAT10N # <br /> ( 1 <br /> PHONED EXT, SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR MartyWeithman CHECR. IfBILUN13AMEss ✓� <br /> BUSINESS NAMEPHONE # EXT' <br /> Service Station Systems , Inc . 408 1 213-6038 <br /> HOME or MAILING ADDRESS FAX # <br /> 680 Quinn Ave (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNiOWLEDGBMENT: 1 ; the undersigned property or business owner, operator. or authorized agent df $an.i <br /> acknowledge that all site and/or project 'specific ENVIRONMENTALNEALTH DEPARTM> NT I ourly :charges associated with this project <br /> or activity will be billed tome or my business as idendfed on this form. <br /> i <br /> I also certify that l have prepared' this application and that the work to be performed Will be done in: aceordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and. FEDERAL <br /> , laws. <br /> APPLICANT'S SIGNATURE: { QL ih ? V .- /y DATE: 6/21 //2019 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTNERAUTHORIZED AGENT ✓❑ Compliance Officer <br /> If APPLICANT is not the:B1LLINGPARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION , When applicable, I , the owner or operator of the property lot ated 'at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data andlorenvirontnentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it available and .at. the ;same time, ii 'l <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED' UST inspection <br /> COMMENTS: <br /> ACCEPTED 13Y' EMPLOYEE #: DATE; <br /> ASSIGNED TO ' EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed)' SERVICE.CODE: P i' E' <br /> Fee Amount' Amount Paid Payrnenf pate <br /> Payment Type Invoice ,# Check .# Racelysd: By : <br /> END 48-02-025 <br /> $R FORM (Golden Rod) <br /> REVISED f 1 /17!2003 <br />