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SAN JOAVOIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station �- <br /> OWNER/OPERATOR <br /> Tesoro Corporation CHECK IfSILUNGADDRESSO <br /> FACILITY NAME Shell(Tesoro) <br /> SITE ADDRESS 2448 W Kettle m n Lane, di, Lockeford CA 95242 <br /> Street Number n Name I city I ZID Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3450 S. 344th Way <br /> Street Number Street Nam <br /> CITY Auburn STATE WA ZIP 98001 <br /> PHONE#t Ear. APN X LAND USE APPLICATION 0 <br /> ( 2538196-8700 <br /> PHONE V EXT. BOS DISTRICT <br /> LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK IfBILUNGADDRESS <br /> � <br /> BUSINESS NAME Able Maintenance, Inc PHONE III Er. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS FAx# <br /> 680 Quinn Ave <br /> (408 ) 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 /> 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:IL(O�-,6> Lk-V ---k-t DATE: 2/28/2011 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OT14ERAUTHORIZED AGENT❑ Compliance Officer <br /> 1fAPPLICANT 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 is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST inspection i t &-T ,� 172 GI F t% !�CEIVED <br /> COMMENTS: MAR ^ ^0q1 <br /> SAN JOAQUIN coo.N <br /> HEALTH DEPA TME T <br /> ACCEPTED BY: t E i EMPLOYEE#: SLI DATE: -3 L (/ <br /> ASSIGNED TO: C7 � i` EMPLOYEE M -jSP r L4 2 L DATE: .-2 Z / <br /> Date Service Completed (if already completed): SERVICE CODE: / <�k P i E: <br /> Fee Amount: ,� , Dr� Amount Paid is 3�� p D Payment Date 31 ZI <br /> Payment Type ✓ Invoice# Check# 9 p Received By: <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />