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SAN JOAA COUNTY ENVIRONMENTAL HEALTIEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY,Jr <br />SERVICE REQUEST # <br />gas station <br />�# <br />j C/ <br />� U O �o �o `4 �J <br />OWNER /OPERATOR <br />HOME or MAILING ADDRESS 680 Quinn Ave <br />EMPLOYEE #: <br />RADC Enterprises <br />) 213-6026 <br />CHECK IfSiLUNGADDRESS� <br />FACILITY NAME Tracy Blvd Shell & Mini Mart <br />ZIP 95112 <br />Date Service Completed (M alrea completed): <br />SITE ADDRESS 3725 N Tracy B <br />d, Tracy5376 <br />f <br />P 1 E:,' <br />Fee Amount: - <br />Amount Paid <br />-OD Payment Date <br />WOO Number <br />Olfteffon <br />invoice # <br />StrottName <br />Check # JM14 <br />city <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Creel Name <br />CITY <br />STATE ZIP <br />PHONE #i EXt. APN * <br />LAND USE APPLICATION # <br />PHONE 82T <br />SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Marty Weithman <br />CHECK)fBILLING ADDRESS � <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 />EMPLOYEE #: <br />FAR# <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 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:/1(Cu� ti E t2 L( DATE: 1/21/2013 <br />PROPERTY/ BUSINESS OWNERD OPERATOR/ MANAGER ❑ OTNERAUTHORIZED AGENTs) Compliance Officer <br />IfAPPL1CANT is not fhe ftixG 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 />COMMENTS: <br />n <br />ACCEPTED BY: '1 <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (M alrea completed): <br />SERVICE CODE: <br />P 1 E:,' <br />Fee Amount: - <br />Amount Paid <br />-OD Payment Date <br />a �3 <br />Payment TyptY I <br />invoice # <br />Check # JM14 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />2u(--- <br />