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.r. <br />C7 <br />SAN JOAQUIN C0UNTV."VIR0Nmra4TAL $EALTm DLPARTMBNT <br />$PfflCE REQUEST <br />Typti of Business or Propa t)r FACILITY 10 a SERVICE REQUEST d <br />gas station <br />cgtl OR 0075-771 <br />bWNER / QP@RATOR <br />PRMI act: <br />(406.1213-6038 <br />Anabl <br />t:l{aCKI(t3lrtrNe NImt9� <br />FAcs.IrYNAMETracy Blvd Shell & Mini Mart <br />OIY San Jose <br />OWE CA 7* 95112 <br />oYaEtl:no <br />ll i n <br />Si3EADDfkt 88 3725 M. Tracy vd Tracy, <br />Mr GOOD <br />Homr: or MAluW-AWRM Ofbiftaranttranl Site Address). <br />Fee Amount: Amount Paid 3 C1 (9 0 C.7 <br />St � tau Cs <br />! a <br />CITT <br />STATE ZAP ENVIRONMENTAM <br />check# so <br />HEALTH DEPAATM <br />IRRME91 <br />ON <br />LAWUseAPK#Aww-0 <br />Pwmo#2 VIT. <br />BOB Dlsrraar <br />3.ocAr4w 00ve - <br />( <br />0 <br />CONTRACTOR/ S +'R' ICE RRQUESTOR <br />f2EQUt BTOR Marty Welchman <br />chwKi(ial AW4880 <br />8usivEss Nos Service Station Systems <br />40MM"M <br />PRMI act: <br />(406.1213-6038 <br />Home or MA>Lum ADDRESS 680 Quinn Ave <br />Aocopm Bw <br />FAX# <br />8 213-6026 <br />OIY San Jose <br />OWE CA 7* 95112 <br />BILLING AQQQ_V4MW=: f, the undeMgn*ed property or btiditess owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific MVIRONMENTAL HEALTH DEPARTMOT hourly cbarges associaiQ with this prged <br />Vitt' will be billed to me or my business as Idartified on this form. <br />I also certify that I hwe•prepered We application and that the work to be performed will be done in accordance with A SAN 10MQUM <br />COUNTY Ordinance Coder, Standards, STATS and FBDMUL htw8, <br />APPUCANT'8•SIGNATM1 1 <br />U <br />11/2W2014 <br />PROPERTY/BUSIPIM0""M OnPATOR/MAMOM ❑ OTNBRAtiTgojttzBDAia$N:'WI Compliance Officer <br />V'APPVMNT is trot the &LUM proof orarrlhorisado►t to stgn k regttfra d'Nle ' <br />AUI fi="n0N TO RELIABE INZQI�MATION: When applieaak, I, the owner err operator cf the prope�-lQoattfd bt ihs- <br />r ar r Rnrrcir� <br />above .site Mildress, hereby su(horfze the riel*eptimy Mfrd All results, gomeo pical. date• And/or envfionmerrtxllrtft sss rt <br />information to thb SAN JOAQUtN COUNTY ENViRDNh tillTA)..I- &-T l DSrA 7irtW es soop as kis Aveffi6le and at the saryte iiinb'li (s <br />provided tome of r9y repfcseniafiva. <br />TYP94.SERVi6iRWUE8•ft UST Inspection <br />PAYMENT . <br />40MM"M <br />DEC $'2 2015 <br />SAN JOAQUIMME CNIDEHEPAR•ME <br />Aocopm Bw <br />EmPL 01Y E #; <br />DAti ;• <br />AsaroNr?G TD:Eiitrt <br />oYaEtl:no <br />ll i n <br />Date Sdrvlce completed (if ah'e q ao tet")., <br />I Pili: a � <br />Fee Amount: Amount Paid 3 C1 (9 0 C.7 <br />Payment Date <br />! a <br />Payment -Type �(._ <br />Invoice# <br />check# so <br />Raoolirod :� <br />EHD 46.-WP26 48 FORM ("On <br />REVISED 11117/2003 <br />9 <br />X <br />IT <br />