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SAN JOAII PIN COUNTY ENVIRONMENTAL HEALTREPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />gas station ::I <br />I r <br />OWNER /OPERATOR <br />Cl <br />Tesoro Refining and Marketing Copany <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Shell (Tesoro) <br />FAX# <br />(408 <br />SITE ADDRESS 35 N Cherokee <br />ane, Lodi <br />I <br />CA 95240 <br />I <br />ZIP 95112 <br />SERVICE CoDE: �� ?- <br />P i E: <br />Str t Number <br />Diwtlon <br />StrntNikmv <br />Payment Date x-3113 <br />city <br />Zia Code <br />HOME or MAIUNG ADDRESS (if Different from She Address) 3450 <br />Check # q o? <br />South 344th Way <br />Street Number <br />tnel Name <br />CITY Auburn <br />STATE WA ZIP 98001 <br />PHONE #11 Exr.APN <br /># <br />LAND USE APPLICATION # <br />i 2538b68700 7 <br />PHONE#2 EXT. <br />i l <br />BOSDISTRICT LOCATIONGODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Marty Weithman <br />,PPGEtVE <br />CHECK N8ILLINGADDRES5� <br />BUSINESS NAME Service Station Systems, Inc. <br />ACCEPTED $Y:�A,;i fl/41 1—"A_EMPLOYEE <br />PHONE# <br />408 <br />EXT. <br />213-6038 <br />HOME or MAILING ADDRESS 680 Quinn Ave <br />ASSIGNED TO: 1Z. <br />FAX# <br />(408 <br />j 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 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: 7fl • ` t-f-Ala,,�-VL, L -k- L,t DATE: 5/22/2013 <br />PROPERTY/ ]BUSINESS OWNERQ OPERATOR/ MANAGER ❑ OTHERAIJTHORiZEDAGENT ✓Q Compliance Officer <br />1fAPPL1CANT is not the B1LUNG P. J? 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 is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: UST inspection %�j <br />,PPGEtVE <br />COMMENTS: <br />�� COUNT <br />;��� <br />vv ps" <br />ACCEPTED $Y:�A,;i fl/41 1—"A_EMPLOYEE <br />#: G�� f ' <br />DATE:, "l <br />ASSIGNED TO: 1Z. <br />DATE: 4 <br />Date Service Completed (H already completed): <br />SERVICE CoDE: �� ?- <br />P i E: <br />Fee Amount: �7 <br />Amount Paid <br />37 S , p <br />Payment Date x-3113 <br />Payment Type <br />Invoice # <br />Check # q o? <br />Received By: iz� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />