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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 1-.PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station : L 1-77J7 OWNER /OPERATOR CHECK ItSILUNG� Chevron USA ADDRESS FACILITY NAME EXT. Chevron D PAF? AL T SITE ADDRESS 213-6038 HOME Or MAILING ADDRESS DATE: FAx 10858 Trinity Prkway, St ckton CA 95219 ) 213-6026 CITY San Jose STATE CA Slreet Number Fee Amount: co Amount Paid 16 3 (. (� , 0 0 city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Check # 3S;?,J Street Number Street Name CITY STATE ZIP PHONE #1 EXT• APN S LAND USE APPLICATION # PHONE #2 EXT• SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR RE NT Marty Weithman CHECK if BILLING ADDRESS BUSINESS NAME Service Station Systems, Inc. PHONE EXT. D PAF? AL T 408 213-6038 HOME Or MAILING ADDRESS DATE: FAx 680 Quinn Ave DATE: (408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: f L.(ci=C DATE: 4/14/2011 PROPERTY IBUSINESS OWNERQ OPERATOR/ MANAGER ❑ OTHERAUTHORIZEDAGENT ❑ Compliance Officer IfAPPLICtNT is not the fiLLiNG PARTY. proof of authorization to sign Is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. r, TYPE OF SERVICE REQUESTED: UST inspection RE NT COMMENTS: APR 1 K 2011 SAN JOAQUIN COUNTY ENViRONMENTHEALTH D PAF? AL T ACCEPTED BY: EMPLOYEE #: qCisl; DATE: ASSIGNED TO: e c -lo- a!) EMPLOYEE #: -Zrlw,,3Gi DATE: Date Service Completed (If already completed): SERVICE CODE: %`2,f 01E: 230 f Fee Amount: co Amount Paid 16 3 (. (� , 0 0 Payment Date 4 S-11 I Payment Type t/ Invoice # Check # 3S;?,J I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003