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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQU ST # <br /> gas station �A QL2--. � <br /> OWNER / OPERATOR <br /> Darren Eppler CHECKIfBILL1NGADDRESS ❑ <br /> FACILITY NAME Unocal 76 (#255886 ) <br /> SITE ADDRESS 2701 W March ane , Stoc ton CA 95219 <br /> Street Number Direction streetName cityC <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number StreetName <br /> CITY STATE zip <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If BILLING ADDRESS <br /> BUSINESS NAME Service Station Systems , Inc. PHONE # EXT* <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAX # <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA 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 /> 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 FEDERAL laws . <br /> APPLICANT'S SIGNATURE ; cyDATE: 12/28/18 <br /> PROPERTY IBUSINESS OWNERO OPERATOR / MANAGER ❑ OTHERAUTHOR1zEDAGENT ✓Q Compliance Officer <br /> If APPLICANT 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 <br /> provided to me or my representative , <br /> TYPE OF SERVICE REQUESTED : UST inspection r rarq <br /> COMMENTS: IVP <br /> ED <br /> JAN o 4 2019 <br /> SAN JOAQUIN COUNTY <br /> HEAL VIRONMENTAL <br /> ACCEPTED BY: � EMPLOYEE M (via DATE; At <br /> ASSIGNED TO . a� EMPLOYEEMelDATE: I C <br /> Date Service Completed (if already completed ) : SERVICE CODE: p 8 PIE ; <br /> Fee Amount: D U Amount Paid a (7p r Payment bate / 4 l <br /> Payment Type Invoice # Check # (4� Received By : 61 <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />