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SAN JOAO COUNTY ENVIRONMENTAL HEALTOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas stations ' � — <br /> OWNER/OPERATOR <br /> Chevron US CHECK If SILL Aoomss❑ <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 1103 S. Main SManteca A 95337 <br /> Street Number e city F..Cody <br /> HOME or MAILING ADDRESS (If Different from Slte Address) <br /> Street Number Stmet Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN* LAND USE APPLICATION <br /> ( l <br /> PHONE#2 ExT. BOSDISTRICT LoCATIONCODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK#SLUNG;ADDRESSO <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# EXT. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS FAX# <br /> 680 Quinn Ave <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLINCT 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 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 laws. <br /> APPLICANT'S SIGNATURE:`qI t�.i.a, tU' -lit DATE: 1/24/2011 <br /> PROPERTY/BusmEss OwNER0 OPERATOR/MANAGER El OTatERAtITNORTzEDAGENT ✓] Compliance Officer <br /> IfAPPLICANT is not the BILIJNG PARTx proof of authorization to sign is required Titte <br /> AUTHORIZATIQN 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 JOAQUJN COUN17_YaENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is <br /> provided to me or my reWiis ntative. <br /> TYPEOFSERVICERE ESTER: UST inspection PAYMENT' <br /> COMMENTS: <br /> - JAN 2 5 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: (,p(,c�E •�"' EMPLOYEE#: 9® DATE: <br /> ASSIGNED TO: IM i&-24 EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: q P i E: 30� <br /> Fee Amount: J 6 610 v Amount Paid 3 to Payment Date ® 2- <br /> Payment <br /> Payment Type ✓ Invoice# Check# Z CJ ✓1 2 Received By: T4-&- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />