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SAN .TOAD —N COUNTY ENVIRONMENTAL HEALTh _EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLINGADDRESS� <br />SERVICE REQUEST # <br />gas station:L <br />r -7-7 3 7 <br />EXT. <br />213-6038 <br />r / 4 / l <br />iC7 <br />" 4� 1 <br />OWNER /OPERATOR <br />FAX # <br />(408 <br />) 213-6026 <br />Chevron USA <br />STATE CA <br />CHECK if BILLINGADDRESS <br />FACILITY NAME Chevron <br />P I E: <br />Fee Amount: 3`7 S. o ti <br />Amount Paid �� ]i <br />Payment Date L-:' <br />Payment Type CAN/J— <br />SITE ADDRESS <br />Check # 2jL� I <br />Received By: <br />10858 Trinity Prkway, <br />Stt Number <br />ree <br />Direction <br />straft Name <br />Zip cole <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street NumberT <br />teal Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT APN # <br />( I <br />LAND USE APPLICATION # <br />PHONE #2 Ext. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Marty Weithman <br />14311V1HkrH-?; ; Fl-LIV3H <br />S T- d4--7-�)- c '7— 1V, t. <br />CHECK if BILLINGADDRESS� <br />BUSINESS NAME Service Station Systems, Inc. <br />ACCEPTED BY: OLE J £ <br />PHONE <br />408 <br />EXT. <br />213-6038 <br />HOME or MAILING ADDRESS <br />680 Quinn Ave <br />ASSIGNED TO: Ll� <br />FAX # <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 />I also certify that l 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, - I i ;tib DATE: 5/02/2012 <br />PROPERTY/ BUSINESS OWNERM OPERATOR / MANAGER ❑ OTHER A1ITHORIzED AGENT[) Compliance Officer <br />1f APPLICAN7 is not the BILLING PARTY, proof of authorization to sign is required Tile <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 />14311V1HkrH-?; ; Fl-LIV3H <br />S T- d4--7-�)- c '7— 1V, t. <br />COMMENTS: <br />A1Nn0:3 NinOVOP NVS <br />ZIOZ E 0 �bW <br />®3A1333 1 <br />N3 VVAVd <br />ACCEPTED BY: OLE J £ <br />EMPLOYEE #: LI % <br />DATE: T1-3 Z <br />ASSIGNED TO: Ll� <br />EMPLOYEE #: L! <br />DATE: 51-3 <br />Date Service Completed (if already completed): <br />SERVICE CODE: c� <br />P I E: <br />Fee Amount: 3`7 S. o ti <br />Amount Paid �� ]i <br />Payment Date L-:' <br />Payment Type CAN/J— <br />I Invoice # <br />Check # 2jL� I <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />