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EUD <br /> ' SEP 1 5 "10 SAN JOA COUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> ENV�HH� EM HEALTH SERVICE REQUEST <br /> PI mm biagauvWroperty FACILITY ID# SERVICE REQUEST# <br /> gas station 3 7 / Z —S'4 U® (a 10 P7 <br /> OWNER/OPERATOR <br /> Chevron USA CHECK IfSILUNGADDRESS <br /> � <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 2905 W Benjamn Holt Dr <br /> St et Number i Direction StreotNome city <br /> HOME or MAILING ADDRESS (If Different from Site Address) PO Box Q <br /> Street NumberStreet Na <br /> CITY Concord STATE CA zip 94524 <br /> PHONE#1 Exi. APN* LAND USE APPLICATION IY <br /> ( 287-7182 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK)f BILuNGADDRESSa <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# Ex*. <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 /> 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: ,,f - 11/-fit*Qc.�,����LL� DATE: 9/14/2010 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENTo) Compliance Officer <br /> 1fAPPL1CANT is not the BILLINGPARTY.proof of authorization to sigh 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. UST <br /> TYPE OF SERVICE REQUESTED:UST inspection PAN-90.1 Efff <br /> COMMENTS: P-1 E CEIVED <br /> SEP 15 2019 <br /> SAN JOAQUIN COUNTY <br /> HEENVIRONMENTAL DEPARTMENT <br /> ACCEPTED BY: L I v F I EMPLOYEE#: ®3 Z DATE: p//-S-//C? <br /> ASSIGNED TO: 13,4 C-K f," EMPLOYEE M -"f- J b DATE: Q 1 5-1t-0 <br /> Date Service Completed (if already completed): SERVICE CODE: /9g PIE: Z-?0 i' <br /> Fee Amount: "re,'ri) Amount Paid D Payment Date <br /> Payment Type J Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />