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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT�I)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station 71 ffo ",��_o /.may <br /> OV+INERIOPERATOR v�-v <br /> Chevron USA CHECKIfBtLUNGADDRESS❑ <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 3355 Hammer ne,Stocliton CA 95212 <br /> Street Number re SOM Name city <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Strept Name <br /> CITY STATE zip <br /> PHONE#1 Ext. APN IF LAND USE APPLICATION$ <br /> I ) 0?2- - Com-?.3 <br /> PHONE#2 Ext. BOS DISTRICT Locano CODE <br /> I ) 13 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK NBILLING 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 /> 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 /> 1 also certify that 1 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: �' !t_(-CLL �'— `�LL � � DATE: 1/14/2010 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT ✓Q Compliance Officer <br /> IfAPPLICANT is not the B/LL NG PaRTt proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: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,�i <br /> provided to me or my representative. �M <br /> TYPE OF SERVICE REQUESTED: UST inspection u 5`T— e—&—rr—d F i 1 TO <br /> COMMENTS: = JLY000 <br /> PQM MEQ�NT <br /> JAN 1 5 20R 30 <br /> ENVIRONMENT HEALTH <br /> ACCEPTED BY: ©C–t 1✓£ EMPLOYEE M 6)3 u W.—I, <br /> ASSIGNED TO: EMPLOYEE M 4f&13 4 DATE: <br /> f l-s 1t,0 <br /> Date Service Completed (If already completed): SERVICECODE: l i E:Z3 vk <br /> Fee Amount: ' 3 4-j 1 U Amount Paid 5 Payment Date � S D <br /> Payment Type t/ Invoice Ill Check# 2 Z 1 Received By: Z fr,— <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />