Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> gas stationDa� � <br /> OWNER / OPERATOR <br /> Corral Hallow <br /> FACILITY NAME Safeway #2600 ` �q <br /> SITE ADDRESS I l <br /> 1987 W 11th St, Tracy CA 95376 <br /> Sheet Number Dstreete <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Stroi /7 <br /> CITY `w <br /> ��7 <br /> PHONE #1 En APN # � a — <br /> ( ) t, <br /> PHONE #2 Exr. 1�✓ <br /> / <br /> REQUESTOR CONT CTOR SER <br /> Marty Weithman <br /> BUSINESS NAME Service Station System , Inc . <br /> HOME or MAILING ADDRESS FAX <br /> 680 Quin Ave (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGE NT: 1 , the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/o project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me r my business as identified on this form . <br /> I also certify that 1 have pre ared 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 FEDERAIL, laws .. <br /> APPLICANT' S SIGN URE : Tuet: U4,0�%� .. � V.—t t�L�L/R-t-�-a DATE: 6/21N2019 <br /> PROPERTY / BUSINESS 9� NERQ OPERATOR / MANAGER ❑ OTNERAUTNORIZEDAGENTQ Compliance Officer <br /> ifAPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION 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 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 . MA <br /> TYPE OF SERVICE REQUESTED: tye#iett— [�( S / /�- �/ <br /> COMMENTS : <br /> SUN � � <br /> 4104 /� O f <br /> q �7#wl y <br /> ACCEPTED BY: r ` V EMPLOYEE #: / QATE; <br /> ASSIGNED TO : Z �� �� EMPLOYEE M. Q ® 3 DATE: �p47 <br /> Date Service Completed (if already completed) : SERVICE CODE � e7 3 P I E :' a <br /> Fee Amount; �f J� Amount Paid LLIS . CO Payment Date 61 )0 9 <br /> a5 <br /> Payment Type Cc� Invoice # Check # S 33 Received By : <br /> C <br /> EHD 4 &02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />