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SAN .TOA • COUNTY ENVIRONMENTAL HEALTHDEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />gas station <br />w� � (C (co q)(3— <br />OWNER / OPERATOR <br />I� <br />RADC Enterprises <br />CHECK IfSILLINOADDRESS <br />FACILITY NAME Tracy Blvd Shell and Mini Mart <br />FAx# <br />(408 <br />SITE ADDRESS 3725 N Tracy Bd, <br />1v Tracy <br />A 95376 <br />ZIP 95112 <br />4'r7Y <br />Street Number <br />ACCEPTED BY: <br />StrW Name <br />city <br />Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />EMPLOYEE #: <br />DATE: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #t EST. <br />( 1 <br />APN 9 <br />LAND USE APPLICATION <br />PHONE #2 Ext• <br />1 ) <br />DOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE R.EQUESTOR <br />REQUESTOR Marty Weithman <br />CHECK If BILLING ADDRESS El <br />BUSINESS NAME Service Station Systems, Inc. <br />PHONE# <br />408 <br />EXT, <br />213-6038 <br />HOME or MAILING ADDRESS 680 Quinn Ave <br />SMr <br />t <br />FAx# <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNOWLEDGEMENT: 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 />I also certify that l 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:i ic,c.c �� � ; �t i DATE: 4/8/2013 <br />PROPERTY/ BUSINESS OWNERC OPERATOR/ MANAGER ❑ OrnzRAUTNORiZEDAGENT ❑ 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 <br />RFCF <br />COMMENTS: <br />SMr <br />t <br />N F8V1 OOv�� <br />4'r7Y <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: �� <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (k already completed); <br />SERVICE CODE: <br />PIE: <br />fl <br />Fee Amount: i v °i <br />Amount Pai <br />7SvU <br />Payment Date <br />fD l3 <br />Payment Type <br />Invoice # <br />Check # . �� 3 <br />Recei d By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />