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SAN JOA* COUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />-T <br />FACILITY ID # <br />CHECK 1fPOLLING ADORES5� <br />SERVICE REQUEST # <br />gas station <br />I�3 �I i' �' <br />En. <br />213-6038 <br />_`�l'(%Q '�,L�� 3 / <br />OWNER I OPERATOR <br />FAx# <br />(408 <br />1 213-6026 <br />Z+NECKitgILt.IHGApORE$S� <br />Chevron USA <br />ZIP 95112 <br />FACILITY NAME <br />EMPLOYEE IRI: (QST <br />Chevron <br />:j i; °j ANT <br />[( <br />SITE ADDRESS 1442 A Colony r and Hw, Ripon CA 95366 <br />EMPLOYEE#: )—(—,�lo <br />Strut Number re <br />City <br />Zip Cc -do <br />HOME or MAILING ADDRESS (If Different from Site Addreaa) PO BOX Q <br />P i E:_) <br />Strut Number <br />Amount Paid '� <br />treel NR <br />CITY Concord <br />STATE CA ZIP 94524 <br />PHONE #t En. <br />( l <br />API * <br />LAND USE APPLICATION # <br />PHONE #2 En. <br />( l <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Marty Weithman <br />CHECK 1fPOLLING ADORES5� <br />BUSINESS NAME <br />Service Station Systems, Inc. <br />MYMENT- <br />RECEIVE® <br />PHONE# <br />408 <br />En. <br />213-6038 <br />HOME or MAILING ADDRESS <br />6$0 Quinn Ave <br />FAx# <br />(408 <br />1 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACRNOWLEj2 EMF•NT: I, 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 1 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 FEOFRAL laws. <br />APPLICANT'S SIGNATURE: � ��� .. yi_.lC�l.�l,,�tt�t-L � DATE: <br />1/2312012 <br />PROPERTY I BUSINESS OWNERO OPERATOR/MANAGER LJ 0THERAt1THQR3zEDAGENTl 1 Compliance Officer <br />1f APPLICANT is not the B1L1JNGf RR7Y. 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 ENVIRONMENTAi. 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 �15 i -- <br />COMMENTS: <br />CoMMENTs: <br />MYMENT- <br />RECEIVE® <br />JkA 2 4 2012 <br />SAN JOAOWN NOONpyr <br />EN",f <br />ACCEPTED BY; GCt/' <br />EMPLOYEE IRI: (QST <br />:j i; °j ANT <br />[( <br />ASSIGNED TO: ����! <br />EMPLOYEE#: )—(—,�lo <br />DATE: z IZ <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P i E:_) <br />Fee Amount:�S `� <br />Amount Paid '� <br />Payment Date I I Z <br />Payment Type <br />Invoice # <br />Check It <br />Received B <br />EHD 48-D2-025 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />