Laserfiche WebLink
SAN JOA(1—A COUNTY ENVIRONMENTAL HEALTh _.EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station <br />%'7 3 7 <br />`S'/` <br />OWNER /OPERATOR <br />CHECKif01LUNGADDRESS❑ <br />Chevron USA <br />FAx <br />(408 <br />FACILITY NAME <br />CITY San Jose <br />Chevron <br />ZIP 95112 <br />SITE ADDRESS 10858 Trinity P <br />rkway, St <br />ckton CA 95219 <br />EMPLOYEEM <br />6 3 DATE: <br />street umber <br />reStr"t <br />SERVICE CODE: Q) <br />Name <br />CI <br />Amount Paid <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Payment Date ';j <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE 91 ExT. <br />API * <br />LAND USE APPLICATION N <br />PHONE #2 Ext. <br />SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RECIUESTOR <br />Marty Weithman <br />4e:%4t)F—(T <br />CHECKIISILLINGADDRESSM <br />BuslNEss NAME Able Maintenance, Inc <br />PHONE# <br />408 <br />EXT. <br />213-6038 <br />HOME or MAILING ADDRESS <br />680 Quinn Ave <br />MAR 2 2 2012 <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 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 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: 114 fz C Zc t, I, it-- tl L "l. /- t `; DATE: 3/21/2012 <br />PROPERTY / BUSINESS OWNERM OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT E) Compliance Officer <br />1fAPPLICANT 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 US -r <br />4e:%4t)F—(T <br />COMMENTS: <br />RECEIVED <br />MAR 2 2 2012 <br />SAN ,IOAGIUIN COUNT y <br />Ei`gViI40MEN <br />ACCEPTED BY: <br />EMPLOYEE: <br />��p Fti1� lZ <br />ASSIGNED TO: <br />EMPLOYEEM <br />6 3 DATE: <br />Date Service Completed (H already completed): <br />SERVICE CODE: Q) <br />1 PIE: 2C)� > <br />Fee Amount: SOG <br />Amount Paid <br />Payment Date ';j <br />Payment TypeInvoice <br /># <br />Check 0 <br />Received BYE L1 <br />END 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />