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SAN JOA*COUNTY ENVIRONMENTAL HEALTOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station <br /> OWNER/OPERATOR <br /> Elizabeth Okupe CHECK lfBlLUNCADOREss® <br /> FACILITY NAME Mobil <br /> SITE ADDRESS 401 W KettlemaLane <br /> Street Number ro n Name city I Code <br /> HOME or MAILING ADDRESS (if Different from Site Address} <br /> Street Number tree/Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN LAND USE APPLICATON# <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE. <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR MartyWeithman CHECK If BILLINGAODRESs0 <br /> BUSINESS NAME PHONE# EXT. <br /> Service Station Systems, Inc. 408 213-6038 <br /> HOME Or MAILING ADDRESS FAX# <br /> 680 Quinn Ave (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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: t;V e yU°.-e.ui-u.�!�t DATE: 2/20/2018 <br /> PROPERTY/BUSINESS OWNERM OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT Compliance Officer <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFg MATION: 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* t is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST inspection <br /> COMMENTS: <br /> ys N '�Qtj, <br /> �94"A/0 pop <br /> MFN <br /> ACCEPTED BY: laeua <br /> EMPLOYEE#: ctwf DATE: <br /> ASSIGNED TO: QQbW— EMPLOYEE M DATE: <br /> Date Service Completed (If already completed): SERVICE CODE; R P 1 E; <br /> Fee Amount: Amount Paid C�S� D� Payment Date y <br /> Payment Type Invoice# Check# �1�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />