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SAN JOAQuIN COUNTY ENVIRONMENTAL HEALTH 1vEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />SERVICE REQUEST # <br />gas station - 7 3 -7 <br />S'4 b 05"a-3 &6 <br />OWNER /OPERATOR <br />Chevron <br />� <br />USA <br />CHECK ifBILLING ADDRESS <br />FACILITY NAME Chevron <br />FAX# <br />SITE ADDRESS 10858 <br />TrinityPark Way <br />Y <br />(408) <br />Stockton <br />F5219 <br />tet umber <br />re <br />CI <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />SUM NaMt <br />CITY <br />STATE ZIP <br />PHONE 01 ExT• <br />APN tF <br />LAND USE APPLICATION <br />( 11©tPE <br />r(',, / <br />C.'Z0— <br />PHONE #2 ExT• <br />( ) <br />SOS DISTRICT LOCATION ODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REDUESTOR <br />Marty Weithman <br />CHECKlf SILUNGADDRESS❑ <br />BUSINEss NAME Service Station System, Inc. <br />PHONE# <br />408 <br />EXT. <br />213-6038 <br />HOME or MAILING ADDRESS 680 Quinn Avenue <br />FAX# <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 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:6" Vl� l I1.- �� (/yl� DATE: 9/18/09 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER El OTHER AUTHORIZED AGENT ✓O 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. (l. /C 1% PA 1i. <br />TYPE OF SERVICE REQUESTED: UST inspection <br />COMMENTS: <br />SEP 2 1 2009 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />ACCEPTED BY: OC L c/E f EMPLOYEE #: DATE: U <br />ASSIGNED TO: 8 C- �('" EMPLOYEE #: `f aP3 /_ DATE: c� I <br />Oq <br />Date Service Completed (If already completed): SERVICE CODE:g8 PIE:..23t7 p <br />Fee Amount: © O Amount Paid 3145— Payment Date 9 1 -2-110 <br />1 <br />Payment Type 1� Invoice # Check # Z 1 Lk Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />