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SAN JOA&COUNTY ENVIRONMENTAL HEALT MAKPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station <br /> OWNER <br /> Chevron USA CHECKIfftUNoADDREaR <br /> 10 <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 4344 Waterloo lid.rss. <br /> ber <br /> - &is C292 <br /> HOME or MAtmG ADDRESS (If Different from site Address) <br /> Vee6 Number SUM Nam <br /> CITY STATE zip <br /> PHONE#i Ext. APN 9 LAND USE APPUCA71ON s <br /> ( 1 <br /> PHONE 02 En. 803 DISTMCT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK 1f AILLINGi A22= ✓ <br /> BUSINEss NAME Service Station Systems, Inc. Err, <br /> 408 213-6038 <br /> HOME orMmumctADDRESS 680 Quinn Ave FAx# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> &LING ACKNg M=: I, 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 at)SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: U-_ /; DArE, 1/14/2010 <br /> PROPERTY/BusmEssOWNERQ OPERATOR/MANAGER OTnzRAuTHOR zEDAGENTQ Compliance Officer <br /> IfAPPLX4A7 is not the 8-14 NG PARTY proof of authorization to sign is required rifle <br /> AUTHORIZATIQ,jVV Tfl RELEASE 11SRMATION:When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical dela 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 /> ACCEPTED BY: EMPLoYEE#: DAte: <br /> Ass1GNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERM CODE. p i E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice 0 Check# Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />