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SAN JOAA COUNTY ENVIRONMENTAL HEALT*VPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station ��� /? S' �� ,J/7 / <br /> OWNER/OPERATOR <br /> Chevron USA CHECK IfOILUNoADDRESSO <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 4344 Waterlood <br /> S net umber 95e-os <br /> HOME or MAILING ADDRESS (If Different from Site Addresa) <br /> Street Number treat Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN S LAND USE APPLICATION# <br /> PHONE#2 Ext. SOS DIswhc*' LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RECIUESTOR <br /> Marty Weithman CHECK if BILLING ADDRESSO <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# Ely. <br /> 408 213-6038 <br /> HOME Or MAILINa ADDRESS 680 Quinn Ave FAx# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA 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 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: It fid,( U ���,'��t_ i ,L it DATE: 1/14/2010 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT Compliance Officer <br /> 1fAPPLICAMT is not the BILL/MG 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 environmentallsite 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 /> N <br /> TYPE OF SERVICE REQUESTED:UST inspection <br /> COMMENTS: <br /> JAN 1 5 2010 JAN 1 coin <br /> SpNEROu�Ehff ENT <br /> ENVIRONMENT HEALTH �"0 P' <br /> PERMIT/SERVICES <br /> ACCEPTED BY: L_/ E f EMPLOYEEDATE: r es— 'V <br /> ASSIGNED TO: VV U r./ EMPLOYEE 9°f-eel DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / gay 11E: �3ne <br /> Fee Amount: 2f3 LlScry) Amount Paid 34s — Payment Date (� <br /> Payment Type Invoice# Check# �-O c` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />