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SAN JOAQ* COUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />gas station <br />600-P5����� <br />OWNER/ OPERATOR <br />PHONE# <br />408 <br />fZ4DC Enterprises <br />CHECK ifBILUNOADORESS❑ <br />FACILITYNAMETracyBlvd Shell and Mini Mart <br />FAX# <br />(408 <br />SITE ADDRESS 3725 N Tracy B <br />d, TracyA <br />95376 <br />ZIP 95112 <br />twillIA 0ANTAL <br />SlreetNumbar <br />n <br />Stmet <br />Name <br />city <br />zip <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />#: <br />DATE: - - _ <br />._ i a i I (- <br />Strset Number <br />StreeL Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN * <br />-[ (). � <br />LAND USE APPLICATION # <br />( ) <br />I:21-IC�10 <br />Check # <br />PHONE #2 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTUR <br />REQUESTOR Marty Weithman <br />' ,�-i} <br />CHECKIfBILLING ADDRESS� <br />BUSINESS NAME <br />Service Station Systems, Inc. <br />PHONE# <br />408 <br />EXT. <br />1 213-6038 <br />HOME or MAILING ADDRESS 680 Quinn Ave <br />jUL, 2 9 2016 <br />FAX# <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNOWLEDGMENT: 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 FEDERA�I` 18WS. <br />APPLICANT'S SIGNATURE: ��U1C a C ' 0 ��t�� LL.-� -1 DATE: 7/28/2016 <br />PROPERTY/ BUSINESS OWNER OPERATOR / MANAGER ❑ OTnER AUTHORIZED AGENT Q Compliance Officer <br />IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION 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 L c� "" <br />' ,�-i} <br />PAYMENT <br />COMMENTS: <br />jUL, 2 9 2016 <br />SAN JOAQUIN COUNTY <br />twillIA 0ANTAL <br />p5# ,g- - i k ,;iI*A TMENT <br />ACCEPTED BY: n <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO:EMPLOYEE <br />E 'I C � ace <br />#: <br />DATE: - - _ <br />._ i a i I (- <br />Date Service Completed (if already completed): <br />SERVICE CODE: ` <br />PIE:: <br />Fee Amount: Z) - �1 , <br />Amount Paid <br />-[ (). � <br />Payment Date <br />Payment TypeInvoice <br /># <br />Check # <br />Rec ved B . <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />