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SAN JOAN COUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station :7L 3 7 7 Z. S410106-00-5-6 <br /> OWNER/OPERATOR <br /> Shell Oil Products CHECK IfBILUNOADDRESSi: <br /> FACILITY NAME Shell <br /> SITE ADDRESS 2375 W Grant Line Zia Cod* <br /> tumber city <br /> HOME or MAILING ADDRESS (If Different from Site Address) 20495 TS <br /> Wilmington Ave <br /> Str"tNumberStroal Name <br /> CITY Carson STATE CA Zip 90810 <br /> PHONE#1 EXT. APN* LAND USE APPLICATION# <br /> ( 310416-2207 2 t (Q 2AV-17 <br /> Pw*E#2 EXT. BOS DISTRICT LOCATION CODE <br /> I 1 ,S' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUIESTOR Marty Weithman CHECK NBILUNGADDRESS <br /> � <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# EXT. <br /> 408 213-6038 <br /> HoMEorMAILING 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 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:l'tua;u�, U. /u- -, DATE: 5/25/2010 <br /> PROPERTY/BUSINESS OWNERG OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT E) Compliance Officer <br /> If APPLICANT 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 SERVICE REQUESTED: UST inspection P�M� Q �Lc�n W it I IJ <br /> COMMENTS: R <br /> a� , 61010 k4AY v 6 L'di0 <br /> 0KN <br /> PERM,iTSERVICES <br /> ACCEPTED BY: C-1 j k t oe-j EMPLUYEE#: o?�L f DATE: 2 f V <br /> ASSIGNED TO: t EMPLOYEE#: 2-1 DATE: d_:? <br /> Date Service Completed (H already completed): SEMCE CODE: Q PIE: SOS <br /> Fee Amount: 3`1-S OT Amount Paid ' S 0 C7 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />