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SAN JOAQ N COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE RE QUEST# <br />gas station <br />CHECK IfBILLWGApDRESS <br />P <br />J`"/200 &q/4® <br />OWNER/ OPERATOR <br />EXT, <br />ASSIGNED TO: (2411 LI <br />Elizabeth Okupe <br />408 <br />CHECK if BILLINGADDREgs <br />FACILITY NAME USA(Tesoro) <br />FAX # <br />SITE ADDRESS 401 W. Kettlma <br />Ln, Lodi <br />A 95240 <br />(408 <br />) 213-6026 <br />CITY San Jose <br />Str et NumberDimollon <br />ZIP 95112 <br />Streetame <br />CIZIP <br />Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Namo <br />CITY <br />STATE <br />zip <br />PHONE #t ExT. <br />APN # <br />APPLICATIONPHONE#2 <br />— PLANDUSE <br />Exr• <br />ISTRICT <br />LOCATION C DE <br />CONTRACTOR SERVICE • • <br />REQUESTOR <br />% <br />Marty W2lthman <br />CHECK IfBILLWGApDRESS <br />BUSINESS NAME Able Maintenance, Inc <br />PHONE# <br />EXT, <br />ASSIGNED TO: (2411 LI <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />FAX # <br />680 Quinn Ave <br />Fee Amount: % <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BI LIL NG ACKNQWLEDGEMEN: 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 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:�u � :-1 464LA �. DATE: 2/17/2014 <br />PROPERTY / BUSINESS OWNERC OPERATOR/ MANAGER L_I OTHERAUTHORIZEUAGENT ✓) Compliance Officer <br />IfAPPLIC.fNT is not the BILLING PARTY proof of authorization to sign is required Title <br />AJTIIQRIZATION TO MEASE INFQ1 ATIQN: 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 ' <br />% <br />COMMENTS: <br />Cl FQ <br />&4,V J04 <br />ZhV7 011#i <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: % [ <br />7 <br />ASSIGNED TO: (2411 LI <br />EMPLOYEE M Z <br />DATE:. - <br />Date Service Completed (if already compl ted): <br />SEWCECODE; <br />PIE: <br />Fee Amount: % <br />Amount Paid <br />37,5, <br />Payment Date <br />i <br />Payment Type <br />invoice # <br />Check # <br />Rece ved By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 Lo <br />vv' <br />