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SAN JOA,,oIN COUNTY ENVIRONMENTAL HEALTr, DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />3 <br />OWNER /OPERATOR <br />Err. <br />Able Maintenance, Inc <br />Chevron USA <br />408 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Chevron <br />FAx <br />Fee Amount: �^ C-4 <br />680 Quinn Ave <br />Paymen Date <br />SITE ADDRESS 10858 Trinity P <br />rkway, Stckton <br />I <br />CA 95219 <br />Check # e�601 <br />(408 <br />) 213-6026 <br />CITY San Jose <br />SVest Numbs <br />r-emn- <br />SIrest Name <br />city <br />I e <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />§trset Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. APN # <br />( 1 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( I <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Marty Weithman <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />EMPLOYEE #: <br />PHONE# <br />Err. <br />Able Maintenance, Inc <br />DATE: <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />FAx <br />Fee Amount: �^ C-4 <br />680 Quinn Ave <br />Paymen Date <br />3/ <br />Payment Type y <br />Invoice # <br />Check # e�601 <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <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 />1 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 SIGNATURE: L(�y �;, . ` . '� ya�(�t l� DATE: 12/27/2012 <br />PROPERTY/ BUSINESS OWNER= OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ✓Q Compliance Officer <br />IfAPPLICANT 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. <br />TYPE OF SERVICE REQUESTED: UST inspection <br />COMMENTS: <br />ACCEPTED BY: J <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P i E: a <br />Fee Amount: �^ C-4 <br />Amount Paid -7J 0 <br />Paymen Date <br />3/ <br />Payment Type y <br />Invoice # <br />Check # e�601 <br />Recel ed By: <br />EHD 48-02-025 SR FORM (Golden od)VL--' <br />REVISED 11/1712003 <br />