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SAN JOAt t COUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station Lb2 <br /> /l�5171 '7SOWNER/OPERATOR <br /> Chevron USA CHECKIIBILUNGADDRESSCI <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 1960 W 11th St racy CA5376 <br /> Strom NumberNaml— city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Str#tt Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> { ) ,z� - ®w—O/ <br /> PHONE#2 Ext. BIDS DISTRICT LOCATION CODE <br /> { 1 <br /> CONTRACTOR J SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECKIIftUNGADDRESS <br /> � <br /> BUSiNEss NAME Service Station Systems, Inc. PHONE# Er, <br /> (408_L213-6038 <br /> HOME or MAILING ADDRESS FAx# <br /> 680 Quinn Ave <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 some, <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 we 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: V-�i+'�t t c 1.u�,c�,y DATE: 1/14/2010 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHERAUTHORiZEDAGENT ✓Q Compliance Officer <br /> If-4PPLICANT is not the BILLING PARTY,proof of authorkadon to sign is required Title <br /> AUTHORIZATION 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 environmentaysite 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 ( ='� l o—o C 1,7 — nn <br /> COMMENTS: PAYMEN <br /> RECEIVED JAN 1 5 2010 <br /> JAN 15 2�1 RO1 HENT HEALTH <br /> S�jO,RONMENTA RMiT/SERVICES <br /> ACCEPTED BY: (��_i �f 1 i EMPLoyEE*'p ,-2DATE: <br /> ASSIGNED TO: t �,� y�J EMPLOYEE#: -�Oq DATE: �/l c,, <br /> Date Service Completed (it Aready completed): SERVICE CODE: P i E: • -3t,�• <br /> Fee Amount: J Amount Paid .93ttS 17 0 Payment Date <br /> Payment Type Invoice# Check# yZ Z Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />