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SAN JO. -JIN COUNTY ENVIRONMENTAL HEAL... DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITI'ID# SERVICE REQUEST# <br /> -T <br /> gas station �' S'RQ <br /> OWNER/OPERATOR <br /> Tesoro Refining and Marketing Copany CHECK IfBILUNGADDRESS <br /> ❑ <br /> FACILITY NAME Shell/Tesoro <br /> SITE ADDRESS 2448 W Kettlemro n Lane, di CA 95242 <br /> Street Number D" ame Ci <br /> ty Z11)Cod* <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3450 South 344th Way <br /> Street Number treat Na <br /> CITY Auburn STATE WA ZIP 98001 <br /> PHONE#1 ExT. APN* LAND USE APPLICATION <br /> ( 253W68700 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK It BILLINGADDRESS� <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# ExT. <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 some, <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: IiI�'� � _ �,�{,C��f_�i� s.tit� DATE: 5/23/2011 <br /> PROPERT)'/BUSINESS OWNERM OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E) Compliance Officer <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 /> TYPE OF SERVICE REQUESTED: UST inspection FI i l <br /> COMMENTS: FCS' <br /> MAY 252011 <br /> ,AN JOAQUtlJ COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMF- <br /> J <br /> ACCEPTED BY: < EMPLOYEE M L DATE: ice..,t <br /> 2 <br /> ASSIGNED TO. ,_1 `. L EMPLOYEE#: r'7 DATE: <br /> 11 <br /> Date Service Completed (if already compiet SERVICE CODE: f_. P I E: 23c'� <br /> Fee Amount: ,� Amount Paid 3 Payment Date ej 2 S 1 <br /> Payment Type Invoice# Check# 3 5 s Received By: <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2D03 <br />