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SAN JOA _ tN COUNTY ENVIRONMENTAL HEALT.- DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />REQUEST # <br />gas station <br />i 7 �3�- <br />F;ZSERVICE <br />o 6310 9 <br />OWNER /OPERATOR <br />HOME or MAILING ADDRESS <br />680 Quinn Ave <br />CHECK if131LUNGADDRESS❑ <br />Chevron USA <br />) 213-6026 <br />CITY San Jose <br />FACILITY NAME <br />ZIP 95112 <br />ASSIGNED TO: 8 s <br />Chevron <br />EMPLOYEE #' C43. <br />DATE: 72-4." <br />SITE ADDRESS 10858 Trinity P <br />rkway, Stckton <br />CA 95219 <br />PiE: 290? <br />Fee Amount: 3(' G �— <br />Amount Paid <br />`� 3 L(e �� <br />Street Number <br />Payment Type <br />Invoice # <br />Check # 3 LL[Lf <br />city <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #t ExT• <br />f ) <br />APN * <br />LAND USE APPLICATION <br />PHONE 02 ExT• <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />RECIUESTOR <br />Marty Weithman <br />P F CEN Eo <br />CHECKIf BILLING ADDRESS <br />BUSINEss NAME Service Station Systems, Inc. <br />PHONE# <br />408 <br />EXT. <br />213-6038 <br />HOME or MAILING ADDRESS <br />680 Quinn Ave <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 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 law's./ <br />APPLICANT'S SIGNATURE: (Ct I`tC L. - �' i Gl C t l tit a L (� DATE: 7/25/2011 <br />PROPERTY/BUSINESS OWNEROPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT❑ Compliance Officer <br />If APPLICANT is not the BILLING PART}, 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 />P F CEN Eo <br />COMMENTS: <br />O <br />262 <br />' <br />NFp.1`N � <br />ACCEPTED BY: <br />EMPLOYEE #: q.9 s O <br />DATE: • Z (. , / f <br />ASSIGNED TO: 8 s <br />EMPLOYEE #' C43. <br />DATE: 72-4." <br />Date Service Completed (If already completed): <br />SERVICE CODE: 1q? <br />PiE: 290? <br />Fee Amount: 3(' G �— <br />Amount Paid <br />`� 3 L(e �� <br />Payment Date Z(p <br />Payment Type <br />Invoice # <br />Check # 3 LL[Lf <br />Received By: _ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />