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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station <br /> OWNER/OPERATOR <br /> Chevron USA CHECKRSiLuN©AODRES9❑ <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 4344 Waterlood Stockto CA 95215 —T - T ZI.Cd. <br /> rest Number Sir"t Name city <br /> HOME or MAILING ADDRESS (If Different from Site Address) PO Box 6004 <br /> Streit Number Street Name <br /> CITY San Ramon STATE CA ZIP 94583 <br /> PHONE A ExT. APN* LAND USE APPLICATION 9 <br /> ( 925442-9002 <br /> PHONE 02 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS ✓0 <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# EXT, <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAx# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLINQ 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 IaWS. <br /> APPLICANT'S SIGNATURE:I'J(C�tLC L-O- 10/22/2012 <br /> �t L L,Ct-L t_. DATE: <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER❑ OTNERAUTHOR1ZEDAGENT Q Compliance Officer <br /> 1fAP,PLICANT is not the BILLINGPARTY,proof of authorization to sign is required Title <br /> A11THORIZATION TO RELEASE INFORMATION: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 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 /> RECEIVED <br /> OCT 2 5 2012 <br /> SAN JOAQUIN COUNTY <br /> EW RO N M ENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE : LDATE: <br /> ASSIGNED TO: EMPLOYEE#: I V1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: S� Amount Paid — Paym `�5 t Date 19- r <br /> Payment Type Invoice# Check# Received By: Z <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />