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SAN JOA " COUNTY ENVIRONMENTAL HEAL W EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID <br />SERVICE REQUEST # <br />gas station <br />I 14p %V� <br />O <br />R Q3'? <br />SP1W _V / <br />OWNER / OPERATOR <br />4% <br />Darren Eppler <br />213-6038 <br />CHECK IfBILUNGAQDRES8® <br />FACILITY NAME Unocal <br />FAX# <br />SITE ADDRESS 2701 March Lae, <br />Stockto <br />CA 95219 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />Street Number <br />DATE: �, 3 <br />lr Name <br />CI <br />e <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Amount Pai <br />�Ulc <br />Street Number <br />Street Name <br />CITY <br />Invoice # <br />STATE zip <br />PHONE #1 ExT` <br />Received By: <br />LAND USE APPLICATION # <br />('zc ci) ��� '7 7 <br />11 Q I q W-) <br />PHONE #2 ExT• <br />"6` 1 � <br />BOS DISTRICT LOCATION CODE <br />(C )( -A) <br />0- C�- 0 j <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Marty Weithman <br />P,9 iM <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Service Station Systems, Inc. <br />I 14p %V� <br />O <br />R Q3'? <br />PHONE# <br />ExT, <br />4% <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />FAX# <br />680 Quinn Ave <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNOWLEDGEMI NT: I, 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 l 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: 'L�CI�i �+ t =r–i��l� DATE, 4/1/2015 <br />PROPERTY/ BUSINESS OWNERQ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Officer <br />IfAPPLiCANT is not the BILLM ,PARTY proof of authorization to sign is required Title <br />A ItITHORIZATION 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 <br />P,9 iM <br />tit (;E1 y <br />COMMENTS: Lk5l- Re -A -MO- <br />I <br />I 14p %V� <br />O <br />R Q3'? <br />APR O <br />3 2u-'3H4��A <br />4% <br />d <br />rx,4. ,,,� <br />ENVIRONMENTAL H <br />PERMIT/SERVIra. <br />ACCEPTED BY: <br />EMPLOYEE #: C <br />7 <br />DATE: _ <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: �, 3 <br />Date Service Completed (if already completed): <br />SERvICECODE: �� <br />—7—parent <br />P/'E: <br />� <br />Fee Amount: ?:)g o <br />Amount Pai <br />390. D� <br />Date'T/32/5 <br />Payment Type <br />Invoice # <br />Check # S'� ��j <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />'F® <br />kLTH <br />