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SAN JOAQU IN COUNTY ENVIRONMENTAL HEALTH ,_rEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas stationQfy�(�,61 <br />CHECKIfBILLINGADDRESSr] <br />► tV <br />n 7 L' �!I <br />r� 111 <br />OWNER / OPERATOR <br />EXT <br />Service Station Systems, Inc. <br />Arco <br />(916_1.503-1529 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Arco <br />FAX # <br />680 Quinn Ave <br />Fee Amount: J� v <br />SITE ADDRESS <br />3 tJ. <br />Payment Date <br />Z <br />(408 <br />) 213-6026 <br />CITY San Jose <br />130 S. Wilsonay <br />ZIP 95112 <br />Street Number <br />Dire t n <br />Slreql Name <br />CItY <br />ZIpCode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />zip <br />PHONE #1 En. <br />APN # <br />LAND USE APPLICATION # <br />( ) <br />15� � 4IJ <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Mark Shaw <br />CHECKIfBILLINGADDRESSr] <br />BUSINESS NAME <br />PHONE# <br />EXT <br />Service Station Systems, Inc. <br />(916_1.503-1529 <br />2 5 3� <br />HOME or MAILING ADDRESS <br />FAX # <br />680 Quinn Ave <br />Fee Amount: J� v <br />Amount Pai <br />3 tJ. <br />Payment Date <br />Z <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNOWLEDGEMENT: 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 />1 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 dFEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 3/25/16 <br />PROPERTY/ BUSINESS OWNERM OPERATOR/ MANAGER ❑ OTIIER AUTHORIZED AGENT ❑ Compliance Manager <br />IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 />A. <br />TYPE OF SERVICE REQUESTED: UST inspection I <br />COMMENTS: <br />fir �?,9 <br />y� o ny �O <br />ACCEPTED BY: ' <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: /moi <br />EMPLOYEE #: <br />DATE: / <br />Date Service Completed (if already completed): <br />SERVICE CODE: 1 <br />PIE: C <br />Fee Amount: J� v <br />Amount Pai <br />3 tJ. <br />Payment Date <br />Z <br />Payment Type V" <br />Invoice # <br />Check # <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />