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SAN JOAN COUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station �'7 �� Cid,]�f tp <br /> OWNER/OPERATOR CHECK if BUNG ADDRESS❑ <br /> Shell Oil Products <br /> FACILITY NAME Tracy Blvd Shell&Mini Mart <br /> SITE ADDRESS 3725 N Tracy B d,TracyA 95376 <br /> ►e t Niunber ►. Cr <br /> HOME or MAILING ADDRESS (If Different from Site Address) 20495 S Wilmington Ave <br /> Street Number trnt Name <br /> Circ Carson STATE CA ZIP 90810 <br /> PHONE#1 Exr. APN 0 LAND USE APPLICATION 11 <br /> ( 310416-2207 2-r2--t70-30 <br /> PHONE#2 Ext. SOS DISTRICT LOCATt:�oDE <br /> t ) <br /> CONTRACTOR.I SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If BILLING ADDRESS <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# ExT. <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. rr <br /> APPLICANT'S SIGNATURE: (I,- CC l,!. k ,t4l�—Lt L , ,, DATE: 4/27/2010 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHERAUTHORIZEDAGENT ✓Q Compliance Officer <br /> 1,f.APPL1CaNT is not the BiLLxvq P,tR7] 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 SERVICE REQUESTED: UST inspection 7- P"MENT <br /> COMMENTS: RECEIVED <br /> APR 2 8 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L t V r t Ig + EMPLOYEE#: 03 z—( DATE: 4 2F it Ci <br /> ASSIGNED TO: (�t%J C--4EMPLOYEE#: ( LFZ' DATE 4 2-4'-/tt 0 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 4 3,t srG,v Amount Paid,:9 5, 0o Payment Date <br /> t <br /> Payment Type Invoice# Check#ayR ceived By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />