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SAN JOA#Ii IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station : <br />E 3 69 L <br />S _ O—0O 1TI? � 0 <br />F <br />OWNER /OPERATOR <br />CHECK If0❑ <br />Tesoro Refining and Marketing Copany <br />LUNG ADDRESS <br />FACILITY NAME <br />HOME or MAILING ADDRESS <br />USA <br />FAx # <br />SITE ADDRESS <br />680 Quinn Ave <br />(408 <br />) 213-6026 <br />CITY San Jose <br />35 N Cherokee <br />lane, Lodi <br />ICA 95240 <br />Date Service Completed (H already completed): <br />SERVICE CODE: t?g <br />t umber <br />rZip <br />PIE: d g <br />Fee Amount: 3 citi <br />Amount Paid <br />CIty <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 3450South <br />344th Way <br />invoice # <br />Street Number <br />Check # <br />Street Name <br />CITY Auburn STATE WA <br />Zip 98001 <br />PHONE 91 Ext. <br />( 25381368700 <br />APN E <br />tri -C3 <br />LAND USE APPLICATION # <br />PHONE 02 Ext. <br />SOS DISTRICT <br />LOCATI� ODE <br />( 1 <br />CONTRACTOR / SERVICE REOUESTOR <br />RECiUESTOR <br />Marty Weithman <br />U S—t F r7— <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Service Station Systems, Inc. <br />PHONE# <br />FIT, <br />JAN 11 2010 <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />FAx # <br />7INL <br />680 Quinn Ave <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 pmject <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: �/j, � t✓ ;u, �;l , �,; k t, � DATE: 1/20/2010 <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT✓Q Compliance Officer <br />1fAPPL1C4NT is not the B1LLJNG PARTY proof of authorization to sign is required ritie <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 <br />U S—t F r7— <br />ZA <br />COMMENTS: <br />rltcoVE01 <br />JAN 11 2010 <br />SAN O <br />/jA U/N COU 7j, <br />H 711 DSP <br />7INL <br />ACCEPTED BY: OL i V E l I[irL <br />EMPLOYEE #: 0 >1 Z' <br />DATE: / �y� O <br />ASSIGNED TO: C - -to t 7— <br />EMPLOYEE #: Lf L,y <br />DATE: <br />Date Service Completed (H already completed): <br />SERVICE CODE: t?g <br />PIE: d g <br />Fee Amount: 3 citi <br />Amount Paid <br />:A45 _ <br />Payment Date <br />I tet/ I D <br />Payment Type ✓ <br />invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />