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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 /( D U Z p g p I <br /> OWNER/OPERATOR <br /> Edgar Rizkalli CHECK IfBILUNGADDRESS <br /> � <br /> FACILITY NAME Diamond Petroleum#550 (Arco) <br /> SITE ADDRESS 550 W.Valpicod, Tracy A 95376 <br /> Street Number Dire I n re Name c, e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number !reel Name <br /> CITY STATE ZIP <br /> PHONE#t Ext. API# LAND USE APPLICATION III <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS <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 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: 7t( LCL,c � • )U.0 t&I,LLtt L 1-: DATE: 11/15/2012 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTO 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 is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST inspection RE <br /> COMMENTS: NOV 19 <br /> 2012 <br /> SAN JOAQUIN COUNTY <br /> EN <br /> VIROMENTAL <br /> HEALTH pEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j <br /> Fee Amount: Amount Paid -72 _ Payment Date / Z <br /> Payment Type Invoice# Check# �j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />