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SAN JO"N COUNTY ENVIRONMENTAL HEAL i n oEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station <br />/737 <br />S2 ao SF 7 9 e' <br />OWNER /OPERATOR <br />CHECK If <br />Chevron US <br />ACCEPTEDEMPLOYEE <br />SILUNG ADDRESS <br />FACILITY NAMEChevronUSA <br />213-6038 <br />HOME or MAILING ADDRESS <br />680 Quinn Ave <br />SITE ADDRESS 10858 Trinity Prkway <br />Sto <br />kton CA 95219 <br />Date Service Completed (H already completed): <br />(408 <br />F <br />S ros umhrrr <br />ro <br />- <br />Sirtyl Name <br />city <br />ZIDC*de <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street NumWr <br />Stmet Na <br />CITY <br />STATE <br />zip <br />PHONE #t EXT. <br />APN X <br />LAND USE APPLICATION # <br />f ) <br />o��oaoi <br />PHONE $2 ExT• <br />( ) <br />SOS DISTRICT (� Loc;7OOpE <br />O Y Y9 <br />CONTRACTOR / SERVICE REQUESTOR <br />RECIUESTOR <br />t <br />COMMENTS: <br />Marty Weithman <br />CHECKIf SILLINGADDRESSM <br />BUSINESS NAME Service Station Systems, Inc. <br />ENVIRONMENT HEALTH <br />PHONE# <br />Em. <br />ACCEPTEDEMPLOYEE <br />408 <br />213-6038 <br />HOME or MAILING ADDRESS <br />680 Quinn Ave <br />FAX # <br />DATE: <br />Date Service Completed (H already completed): <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: �ti( LAA, l -)'�/�..r A ,L—tk; DATE: 11/18//09 <br />PROPERTY/BUSINESS OWNER❑ 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, 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 avilabie and at the same time it is <br />provided to me or my representative. I�iA y AA <br />TYPE OF SERVICE REQUESTED: UST inspection f <br />t <br />COMMENTS: <br />NOV 1 9 2009 <br />ENVIRONMENT HEALTH <br />PERM IT/0"ERVICES <br />ACCEPTEDEMPLOYEE <br />#: <br />DATE: <br />ASSIGNEDTO. <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (H already completed): <br />SERVICE CODE: 7o P f E:�3o� <br />Fee Amount: <br />Amount Paid <br />'5 ,31/5' (D CD <br />Payment Date <br />Payment Type Invoice # <br />Check #9-1 <br />Received By: <br />EHD 413-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />