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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> r. - <br /> as station (K 1 DIW3 <br /> s � _ ,� ? Pr � .aJ <br /> OWNER / OPERATOR <br /> Speedway LLC CHECK It BILLINGADDRESS <br /> FACILITY NAME Speedway <br /> SITE ADDRESS 2448 West Kettl man Lan , Lodi , Ca 95242 <br /> Street Street Name c1tv ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberT treat NaMp <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CCDE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS <br /> BUSINESS NAME Service Station Systems , Inc . PHONE # EXT. <br /> 408 213=6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAx # <br /> l ) <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 1 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 : i(4 #.r ,t.t. U . IUAZG UA4, . DATE : 8/18/2023 <br /> PROPERTY / BUSINESS OWNERC OPERATOR / MANAGER ❑ OTHERAUTHORMEDAGENT ✓Q Compliance Officer <br /> 1fAPPLICANT 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 assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saxi>:ne it is <br /> provided to me or my representative . YM <br /> TYPE OF SERVICE REQUESTED : S A / <br /> Er p <br /> COMMENTS: ! � A Y6 <br /> SA (7 3 <br /> N `SOA <br /> NEgLtH pEfvgRTT L TY <br /> NT <br /> ACCEPTED BY. EMPLOYEE #: DATE; FJZ <br /> ASSIGNED TO : ±I l� L 1 EMPLOYEE M DATE: 2 ?> <br /> Date Service Completed t already completed ) : SERVICE CODE: 00 r 8 P I E ; 8 <br /> Fee Amount: * 4 9U "G Amount Paid 4/ ?( 46D Payment Date g <br /> Payment Type Invoice # Check A90 Recely d By ; <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />