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SAN JOA* 'COUNTY ENVIRONMENTAL HEALTIOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />gas station ::L <br />1-10 "L 51200 & 42r� <br />OWNER /OPERATOR <br />CHECK <br />Tesoro Refining and Marketing Copany <br />if BILLING ADDRESS <br />FACILITY NAME <br />FAX# <br />(408 <br />Shell (Tesoro) <br />CITY San Jose <br />SITEADDRESS 35 N Cherokee <br />n Lodi C95240 <br />� <br />Fee Amount: cc) <br />Amount Paid '3 b 10_ <br />Payment Date <br />Payment Type <br />Street Number <br />gnmWon <br />Strom <br />Narno <br />cityC <br />HOME or MAILING ADDRESS (If Different from Site Address) 3450 <br />South 344th Way <br />Street Number <br />roet Name <br />CITY Auburn <br />STATE WA ZIP 98001 <br />PHONE #1 Ev. <br />APN # <br />LAND USE APPLICATION # <br />( 253868700 <br />PHONE $2 EXT. <br />SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Marty Weithman <br />AYMEN <br />CHECK ItSILLINGApDREss� <br />BUSINEss NAME Service Station Systems, Inc. <br />ACCEPTED BY: ���� <br />PHONE# <br />408 <br />EXT. <br />213-6038 <br />HOME or MAILING ADDRESS 680 Quinn Ave <br />EMPLOYEE #: ' L Z <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 />1 also certify that l 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: ---1 \J • ��1• DA,t,E_ 1/20/2011 <br />PROPERTY /BUSINESSOWNERO OPERATOR/MANAGER ❑ OTHERAtJTHORIZEDAGENT O Compliance Officer <br />1fAPPL1C4NT is not the BILLING PARTY, proof of authorization to sign is required Title <br />A, THORIZATION 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 <br />AYMEN <br />COMMENTS: <br />REC <br />JAN 21 2011 <br />SAN JOAQUiN COUN'N <br />ENVIf10ME14TAL <br />TH DEPARTMENT <br />ACCEPTED BY: ���� <br />EMPLOYEE #: `y- <br />DATE: <br />ASSIGNED TO: A a C A C' A t j <br />EMPLOYEE #: ' L Z <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: cc) <br />Amount Paid '3 b 10_ <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # M <br />Received By. 1�s <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />