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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> gas station TA 000 3ly ty 5 3 <br /> OWNER / OPERATOR <br /> Darren Eppler CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME Unocal 76 <br /> SITE ADDRESS 2701 W March ane <br /> Street Number DI n Strapt Name city ZinC <br /> HOME or MAILING ADDRESS (If Different from Site Address) p� ` , � <br /> Street Number Street Name 'AV <br /> CITY STATE ZIP <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # SqN lrf`• ?023 <br /> NPAj( ) ENVOIgQU/ C <br /> O <br /> PHONE #2 EXT BOS DISTRICT LOCATION IAEpq NrA�NrV <br /> CONTRACTOR / SERVICE REQUESTOR <br /> FHomE <br /> UESTOR <br /> Marty Weithman CHECK It BILLING ADDRESS <br /> NESS NAME Service Station Systems , Inc . PHONE # EXT• <br /> 408 213-6038 <br /> 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 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 1 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 FERE L laws , <br /> APPLICANT ' S SIGNATURE : l�/� 'LLti t� y r 1 y L 'C t �7 Lt Lei til.' DATE: 1 / 19/2023 <br /> PROPERTY / BUSINESS OWNERM OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ✓Q Compliance Officer <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, ? , 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 REQUESTEDt 13 S tlT <br /> COMMENTS: �o Yl a t1b ("Ot <br /> ACCEPTED BY: �� �/jj EMPLOYEE M DATE; <br /> ASSIGNED TO : �a an EMPLOYEE M DATE; 1 <br /> y. <br /> Date Service Completed (If already completed) : SERVICE CODE ; f ' _ .� � S% P 1 E ; Z �` <br /> Fee Amount ; CC Amount Pa*p 7100 Payment Date 7 23 <br /> Payment Type /I P Invoice # Check # 73 853 Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />