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SAN JO UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1 <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />gas station <br />BUSINESS NAME Service Station Systems, Inc. <br />OWNER/ OPERATOR <br />CHECK ifBIUJNGAMMS <br />Chevron USA <br />DATE: <br />FwArry NAME Chevron <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS 680 Quinn Ave <br />SITE ADDRESS 1960 W 11th St <br />Tracy CA <br />5376 <br />Invoice # <br />Check # <br />(408 <br />HOME or Mmullo ADDRESS (if Different from Site Addrees) <br />pO Box Q <br />STATE CA <br />ZIP 95112 <br />Stwt NumberT <br />t Nam <br />CITY Concord <br />STATE CA. zip 94524 <br />PNONE #i En. APN R <br />LAND USE APPLICATION <br />( 925-387-7182 <br />PHow#2 En. <br />( )--- <br />BOB DISTRICT LOCATION CODE <br />T <br />CONTRACTOR ` • • <br />REQUESTOR Marty Weithman <br />COMMENTS: <br />CHECK If1160GAoDRESS <br />BUSINESS NAME Service Station Systems, Inc. <br />DATE: <br />PHONE# <br />EXT' <br />DATE: <br />Date Service Completed (M already completed): <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS 680 Quinn Ave <br />Amount Paid <br />FAX# <br />Payment Type <br />Invoice # <br />Check # <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />ZIP 95112 <br />BILLING ACKNOWL DGEMENT: 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 <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:DATE: <br />in accordance with all SAN JOAQUIN <br />12/12/11 <br />PROPERTY/ BUSINESS OwNERO OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Officer <br />IfAPPIXANT is not the &LLpyQEM proof of authm$zadon to sign is required Title <br />AUJUMIAT10 12 RELEASE 1NF9RMA1ION: 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 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: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (M already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />R@C@Ived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />