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SAN JOAS COUNTY ENVIRONMENTAL HEALTIOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />PAYME NI <br />FACILITY ID # SERVICE REQUEST # <br />gas station <br />9(o 0'—p 6/Zov (&0 f/ <br />OWNER i OPERATOR <br />HOME orMAILINcADDRESS 680 Quinn Ave <br />Tesoro Refining and Marketing Copany <br />CHECK If BILUNts ADDRESS <br />FACILITY NAME <br />CITY San Jose <br />Shell/Tesoro <br />ZIP 95112 <br />SITE ADDRESS 35 N Cherokee <br />ane, Lodi <br />CA 95240 <br />DATE: ((, / Z <br />Date Service Completed (N already completed): <br />tre t Number <br />PIE: rZ 3og <br />Fee Amount: 37S"c?� Amount Paid <br />—' Payment Date fes= 2 <br />i <br />city <br />Check #,3 RIv <br />ec ed y: <br />HOME or MAILING ADDRESS (If Different from Ske Address) 3450 <br />South 344th Way <br />Street Number <br />Street Name <br />CITY Auburn <br />STATE WA zip 98001 <br />PHONE M EXT. <br />APN * <br />LAND USE APPUCATION # <br />( 2538868700 <br />PHONE 02 EXT. <br />BOS DISTRICT LOCnmON CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Marty Weithman <br />PAYME NI <br />CHECK HBILLING ADORESS� <br />BUSINESS NAME Service Station Systems, Inc. <br />PHONE <br />408 <br />EXT. <br />213-6038 <br />HOME orMAILINcADDRESS 680 Quinn Ave <br />FAX# <br />(408 <br />) 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: `�j ( � ,cam-�T CYL i ���t��J DATE: 11/1/2012 <br />PROPERTY/ BUSINESS OWNERID OPERATOR/MANAGER ❑ OTHERAUTHORiZEDAGENT O Compliance Officer <br />IfAPPL1CANT is not the BILLING PARTY proof of authorization to sign 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. <br />TYPE OF SERvicEREQUESTEO: UST inspection <br />PAYME NI <br />COMMENTS: <br />NOV ZU"Z NGV Z" <br />SAN t)CAQUIN COUN1 1�AN J C)UIN OUNTY <br />lNVi1;OME,NTAL E IfROM.EN L <br />I#I sit -111 DEPAFITMF_NTHEALTH CEPAFIT ENT <br />ACCEPTED BY: Lowe <br />EMPLOYEE 05-8 <br />DATE. If Is - 1 2, <br />ASSIGNED To: t -r' <br />EMPLOYEE #: <br />DATE: ((, / Z <br />Date Service Completed (N already completed): <br />SEWCE CODE: <br />PIE: rZ 3og <br />Fee Amount: 37S"c?� Amount Paid <br />—' Payment Date fes= 2 <br />i <br />Payment Type Invoice # <br />Check #,3 RIv <br />ec ed y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />