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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# . <br /> gas station 1 ,5&C6XW <br /> r . <br /> OWNER/OPERATOR <br /> Tesoro Refining and Marketing Copany CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME USA <br /> SITE ADDRESS 2448 W Kettlem n Lane <br /> S rel Number Direction StreetNome Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3450 South 344th Way <br /> Street Number South <br /> Name <br /> CITY Auburn STATE WA Zip 98001 <br /> PHONE#1 Exr. APN f LAND USE APPLICATION <br /> ( 2538)968700 G5d'— 1 U U I <br /> PHONE#Z EZT. SOS DISTRICTLOCATION CODE <br /> _ <br /> I ) 2— <br /> CONTRACTOR <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK II BILLING ADDRESS <br /> BUSINESS NAME PHONE# FIT. <br /> Service Station Systems, Inc. <br /> 408 213-6038 <br /> Home or MAILING ADDRESS 680 Quinn Ave Fuc# <br /> (408 ) 213-6026 <br /> CIT' 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 /> G, �r—C ' <br /> APPLICANTS SIGNATURE: 2 5/25/2010 <br /> [ Cc: c� u DArE: <br /> PROPERTY/BUsrNESs OWNERD OPERATOR/MANAGER❑ OTHER AI)THORIZED AGENT Q Compliance Officer <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTNnR17ATION 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 10 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. HAy MEN <br /> /L <br /> TYPE OF SERVICE REQUESTED:UST inspection i i7& I T <br /> COMMENTS: <br /> MAY 2 5 20 <br /> ENVIRONMENO LTM <br /> HEALTH DEPAR ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED 70: EMPLOYEE P. DATE: �} <br /> Date Service Completed (N already completed): SEWCECODE: P I E: ' } <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type �1 Invoice# -.Ct=" Received By: <br /> EHDREV SED 11/1 / 1 �� l O �Z��` / SR FORM(Golden Rod) <br /> REVISED 11117!2003 l� <br />