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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 ::1 3 "7 <br />1-34W5-93Li6 <br />OWNER /OPERATOR <br />PHONE# Ext, <br />408 213-6038 <br />Edwards Oil <br />CHECK It011LUNGADDRESS � <br />FACILITY NAME Tracy Blvd Shell and Mini Mart <br />CITY San Jose <br />SITE ADDRESS 3725 <br />N <br />y Blvd <br />I <br />EMPLOYEE M J tD <br />Tracy <br />95376 <br />rest umber <br />SERVICE CODE: 1q1 <br />SIMM NameTrac <br />P i E: 02_3 b <br />CI <br />Zia Code <br />HOME or MAILING ADDRESS (if Different from SRO Address) <br />b 0 <br />Payment Type <br />Strut Number <br />Invoice # <br />StreeL bigame <br />CITY <br />STATE ZIP <br />PHONE #i Ext. APN # <br />LAND USE APPLICATION <br />( ) 212.-1713 --3 0 <br />PHONE #; Ext. <br />SOS DISTRICT LocATIgN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Marty Weithman <br />CHECK It D—OLLING ADDRESIM <br />BUSINESS NAME Service Station System, Inc. <br />PHONE# Ext, <br />408 213-6038 <br />HOME or MAILING ADDRESS <br />680 Quinn Avenue <br />ACCEPTED BY: <br />FAx# ' -21a " k0'i <br />Cil snow <br />CITY San Jose <br />STATE CA ZIP 95112 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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. <br />APPLICANT'S SIGNATURE:`h{,f.,l,.ct_l- L', l—t,lz-�AL,t, d1,`; DATE: 9/14/09 <br />PROPERTY / BUSINESS OWNER0 OPERATOR/ MANAGER L --I OMERAl1THORiZEDAGENT 0 Compliance Officer <br />IfAPPLICANT is not the BILLING PARTY, 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: inspection i.� ST %�-+ET�� lT— <br />POME <br />COMMENTS: <br />SEP � 6 20©9 <br />SAt`t JO RONMENTA <br />H�-R-i DEPARTM <br />ACCEPTED BY: <br />Q (tet VE k p!�-A <br />EMPLOYEE #: 3 Zr <br />DATE: q j <br />Lc{ <br />ASSIGNED TO: <br />� r0 <br />EMPLOYEE M J tD <br />DATE: f ' L 09 <br />Date Service Completed (If Aready completed): <br />SERVICE CODE: 1q1 <br />P i E: 02_3 b <br />Fee Amount: <br />3 <br />Amount Paid 3A -5 --Payment Date <br />b 0 <br />Payment Type <br />V� <br />Invoice # <br />Check # 2 `� <br />Recelved ey: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2D03 <br />