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SAN JOA#N COUNTY ENVIRONMENTAL HEALTH—i)EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station <br />• �- <br />12 OG'(� �f`>/ <br />OWNER/ OPERATOR <br />f Q <br />Chevron USA <br />EXT. <br />FACILITY NAME Chevron <br />kJL <br />408 <br />213-6038 <br />SITE ADDRESS 1960 W 11th St <br />Tracy CA <br />5376 <br />D E 1, 1 <br />2011 <br />Stroot Number <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />EMPLOYEE M <br />HOME or MAILING ADDRESS (If Different from Site Address) PO Box Q <br />vI <br />SERVICE CODE:/ <br />Street Number <br />Fee Amount: 3.7 f t'6 <br />CITY Concord <br />STATE CA' ZIP 94524 <br />PHONE A ExT. APN * <br />LAND USE APPLICATION III <br />( 925-287-7182 <br />PHONE #2 Ext. <br />( ) <br />SOS DISTRICT LCCAnoN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�5T/GET/ % i i <br />� <br />Marty Weithman <br />COMMENTS: <br />CHECK HBILLING ADDRESS <br />BUSINESS NAME Service Station Systems, Inc. <br />RECEIVED <br />PHONE# <br />EXT. <br />DEC 14 2011 <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />SAN JOAQUIN COUNTY <br />FAx# <br />680 Quinn Ave <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <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 l 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 OL � �, ���;L,�t��� DATES 12/12/11 <br />PROPERTY/ BUSINESS OWNERQ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTs) Compliance Officer <br />1fAPPL1CANT is nor the BILLING PARTY proof of authorization 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 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 />�5T/GET/ % i i <br />COMMENTS: <br />RECEIVED <br />DEC 14 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: LOLL -If- <br />EMPLOYEE D <br />DATE: (Zit t <br />ASSIGNED TO: ��'4/,) <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:/ <br />P I E: C <br />Fee Amount: 3.7 f t'6 <br />Amount PaidECheck <br />Payment DatePayment <br />Type <br />Invoice # <br /># <br />�— <br />Received <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />