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SAN JOAQIN COUNTY ENVIRONMENTAL HEALTH19EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# EST# <br /> as station �.� C LM <br /> O R/OPERATORChevron ADDRES;� <br /> FACILITYN EChevron <br /> M <br /> S Charter Wa Stockton CA 95206 <br /> net W-1, n n e e <br /> ILING AD ESS (If Different from Site Address) tf Street Num Eer STATEEa*. APN# U USEEa. SOS DIST <br /> C NTRACTOR/SERVICE QUESTOR <br /> RMarty Weithman CNECKd BILLING ADDRESSAME Service Station Systems, I PWONE# ET• <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS FAX# <br /> 680 Quinn Ave <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: I, the under; ned perry or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIR TAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identifie on this fomt. <br /> I also certify that I have prepared this application and al th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and RAL Is <br /> APPLICANT'S SIGNATURE: J (w cam{ ti ' L py tic J DATE: 2/24/2012 <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER❑ iERAUTHORIZED AGENT v❑ Compliance officer <br /> /f APPLICANT is not the BILLW R7Y proof OJautho tion to sign Is required Tjpe <br /> AUTHORIZATION TO RELEASE INPt�RMATION:When applie le,1,the owner or operator of the property located at the <br /> above site address, hereby authorize t release of any and all resin geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COLIN ENVIRONMENTAL HEALTH DEPA ENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUES7USTpectionPAYMENT <br /> COMMENTS: <br /> Re PA'-IIA" <br /> ha Svc - QeQv��Ft FEB 2 8 2012 <br /> RV p S(101117 �Ro«°q <br /> YENTA <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> v 2� <br /> A;SIGNED TO: EMPLOYEE M DATE: <br /> Date Service CD plated (H elre dy completed): SERVICE E: PIE; <br /> Fee Amount: 0 0 Amount Paid lJ✓ <br /> �j1 5 Payment ate 7 1,7 g 12 <br /> Payment Type ,/ Invoice# Cheek 3' Received By: L44 6 <br /> EHDSED 11/1712003 <br /> 1/1 \ / U�t�I��/�/l ��. b (Golden od) <br /> REVISED 1 111 7/2 0 0 3 v t (%t (/tJ L,,/ f I (�.`� <br />