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SAN JOAN,,tN COUNTY ENVIRONMENTAL HEALTh iIEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station CHECK It BILLING ADDRESS BUSINESS NAME Service Station Systems, Inc. PHONE# OWNER / OPERATOR Chevron USA CHECK IfBILUNGADDRESS � FACILITY NAME HOME or MAILING ADDRESS 680 Quinn Ave USA FAx # SITE ADDRESS DATE: � ASSIGNED TO: /� /.- (408 ) 213-6026 CITY San Jose 10858 Trinity Prkway, St ckton CA 95219 I Date Service Completed (if already completed): Street Number Direc n PIE; nName City Zipe HOME Or MAILING ADDRESS (If Different from Site Address) 3 Payment Type v' I Invoice # Street Number street Name CITY STATE zip PHONE #1 Ext. APN # LAND USE APPLICATION # PHONE #2 Er. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Marty Weithman Y ) REC '•t COMMENTS: CHECK It BILLING ADDRESS BUSINESS NAME Service Station Systems, Inc. PHONE# Ex.. c'h QU 408 213-6038 HOME or MAILING ADDRESS 680 Quinn Ave ACCEPTED BY: i� FAx # EMPLOYEE #: -6 -2 C DATE: � ASSIGNED TO: /� /.- (408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Slondards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 5/2/2013 PROPERTY / BUSINESS OWNERM OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Officer IfAPPLICANT is not the BILIJNG PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative TYPE OF SERVICE REQUESTED: UST inspection /�E Y ) REC '•t COMMENTS: Ar®;2 c'h QU ACCEPTED BY: i� EMPLOYEE #: -6 -2 C DATE: � ASSIGNED TO: /� /.- EMPLOYEE #: DATE: .— < iw Z I Date Service Completed (if already completed): SERVICE CODE: i C PIE; Fee Amount:-- Amount Paid L710` 7500 Payment Date 3 Payment Type v' I Invoice # Check # 40$S-- I Recelved By: EHD 46-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 1I I ILS