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r= <br />SAN JOAON COUNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY IID # <br />REQUEST # <br />gas station <br />3�7 g <br />/SERVICE <br />i <br />' )o �-, /,5-/ <br />OWNER/ OPERATOR <br />DATE: $ I! <br />CWECKIfSILUNGADDRESSE <br />Unocal 76 <br />213-6038 <br />HOME or MAILING ADDRESS <br />680 Ave <br />FACILITY NAME Unocal <br />FAX# <br />SITE ADDRESS 2701 W Marchane, <br />11 <br />Stoc <br />ton CA 95219 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />Zip 95112 <br />St et Number <br />Dimilon <br />HOME or MAILING ADDRESS (If Different from Site Andress) <br />t Number <br />StMIName <br />CITY <br />STATE ZIP <br />PHONE #i ExT. <br />( l <br />APN,M <br />LAND USE APPUCATtoN # <br />PHONE 02 EXT. <br />SOS DiSTracr LocATIoN cooE <br />CONTRACTOR _/ SERVICE REQUESTOR <br />REQUtESTOR Marty Weithman <br />c <br />CHECKifBINGApomssm <br />BUSINESS NAME Service Station Systems, Inc. <br />._ <br />F��C Y -i ,, D <br />t�AR � 8 2011 <br />SANJ�e^iffy ou"Jy <br />PHONE# <br />EXT' <br />DATE: $ I! <br />ASSIGNED To: ' G l� �(S <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />680 Ave <br />FAX# <br />Quinn <br />Fee Amount: ��, Amount Paid <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />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: 14A aa. � V .X11 DATE: 3/17/2011 <br />PROPERTY /BUSINESS OWNERd OPERATOR/ MANAGER ❑ OTHERAuTNORinDAGENTQ Compliance Officer <br />JfAPPLICANT is not the Blwyo PAR]Y proof of authorhadon to sign is required ritie <br />AUTHORIZATION TO RELEASE INFORMATIQN: 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 -5-r <br />c <br />COMMENTS: <br />._ <br />F��C Y -i ,, D <br />t�AR � 8 2011 <br />SANJ�e^iffy ou"Jy <br />ACCEPTED BY: C C -L V E t IJA <br />EMPLOYEE #: <br />DATE: $ I! <br />ASSIGNED To: ' G l� �(S <br />EMPLOYEE M ttte3 G <br />DATE: 3 �� <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( c?k <br />P 1 E-_- OQ° <br />Fee Amount: ��, Amount Paid <br />_ <br />Payment Date <br />31 b' <br />Payment Type ✓ <br />Invoice # <br />Check # S C) 3 <br />Received i3 : W -r,.- <br />EHD 48-02.025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />