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SAN JOAC9 COUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />gas station <br />U Jb 0 '3 200 (p C%/DO <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRess� <br />Elizabeth Okupe <br />CHECK IfBIIuNGADDRESS® <br />FACILITY NAME USA(Tesoro) <br />ExT. <br />SITE ADDRESS 401 W. Kettlma <br />Ln, Lodi A 95240 <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />St et Number <br />FAx# <br />e <br />c1tv <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />Street Number <br />Street Na <br />CITY <br />STATE zip <br />PHONE #1 EzT. <br />APN Ili <br />LAND USE APPLICATION # <br />( l <br />0"�- --- <br />j 3. — c( <br />PHONE #2 EXT. <br />$OS DISTRICT <br />LOCATION C DE <br />( ) <br />p < <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR <br />Marty Weithman <br />CHECK If BILLING ADDRess� <br />BUSINESS NAME Able Maintenance, Inc <br />PHONE# <br />ExT. <br />ASSIGNED TO: - <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />FAx# <br />680 Quinn Ave <br />Fee Amount: 3 �--®- <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNOWLEDGEMEN1r: 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:IL ��. C'`z y� L f'i �- A �'e DATE: 2/17/2014 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Officer <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />A�THQRIZATION TO RELEASE IN„FQ Mit ATION: 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: USTjnspest+eftY,!FN <br />COMMENTS: <br />rFO <br />%4N"04 Q(/ <br />Ht;q N aF s <br />�rMEjyy. <br />ACCEPTED BY: <br />EMPLOYEE #: U <br />DATE: <br />7 <br />ASSIGNED TO: - <br />EMPLOYEE #: 14-7--L <br />DATE: <br />Date Service Completed (if already comp/ ad): <br />SERVICE CODE: <br />P / E: , <br />Fee Amount: 3 �--®- <br />Amount Paid <br />Payment Date <br />�p <br />Payment Type <br />Invoice # <br />Check # <br />Rece ved By: <br />EHD 48-02.025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 j <br />o�r,l <br />