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SAN JOAV JIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station .� �CiL� / <br /> OWNER/OPERATOR <br /> Tesoro Corporation CHECK IfSILUNGADDRESS <br /> ❑ <br /> FACILITY NAME Shell(Tesoro) <br /> SITE ADDRESS 2448 W Kettlen Lane, di, Lockeford CA 95242 <br /> Street Number I Name C Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3450 S. 344th Way <br /> Streel Number reel Na e <br /> CITY Auburn STATE WA ZIP 98001 <br /> PHONE#1 Ext. APN 9 LAND USE APPLICATION IN <br /> ( 25386-8700 <br /> PHONE#2 Ext• SOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS <br /> BUSINESS NAME Able Maintenance, Inc PHONE Er. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS FAx# <br /> 680 Quinn Ave <br /> (408 1 213-6026 <br /> CITY San Jose STATE CA 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 /> 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:Ta 0—,Cm—f' U 7 t Ei"Y� (,(,t A�' DATE: 2/28/2011 <br /> PROPERTY/BUSINESS OWNERCI OPERATOR/MANAGER❑ OTHER Al"ORIZED AGENT Q Compliance Officer <br /> 1fAPPLICANT is not the BILLJNG PARTY.proof of authorization to sign is required rifle <br /> AUTHORIZATION TO RELEASEjINFORMATION: 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 SERACEREQUESTED: UST inspection �{ S7 r( F�2 E>F tl— CENED <br /> COMMENTS: � Z 2011 <br /> SAN e1W19ONMENT UIN N T <br /> HFAI TH OEPARTME <br /> ACCEPTED BY: C 7 EMPLOYEE#: f/. <br /> ASSIGNED TO: C. all` EMPLOYEE#: 2 L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <c 5 P l E: U�, <br /> Fee Amount: 1�# Amount Paid f 3&L— p p Payment Date 312-111 <br /> Payment Type ✓ Invoice# Check* y C Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />