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SAN JOAQUOOUNTY'ENVIRONMENTAL REALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY # :VICEQUEST# <br /> Gas Station � t 0 ( �� Q-j Q <br /> OWNER/OPERATOR Valero California Retail Co. CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Valero Service Station <br /> SITE ADDRESS 153 East Eleventh Tracy 95376 <br /> Street Number Direction Street Name ciZipC. <br /> de <br /> HOME or MAILING ADDRESS (If Different from Site Address) 685 Third Street <br /> Street Number Street Name <br /> CITY Hanford STATE CA Zip 93230 <br /> PHONE#1 Eat' APN# LAND USE APPLICATION# <br /> ( 559 ) 583-3231 2>3 - 3 IPSP-07 <br /> PHONE R Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR Charles York CHECK if BILLING ADDRESS❑X <br /> PHONE# Ext' <br /> BUSINESS NAME Triton Construction % 831 227-4729 <br /> HOME Or MAILING ADDRESS FAX# <br /> 2560 Soquel Avenue#202 ( 831 ) 475-8249 <br /> CITY Santa Cruz STATE CA ZIP 95062 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authored agent of same, <br /> acknowledge that all site and/or project specific E NVIRONMENTAL 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 FEDERAL IawS. p <br /> APPLICANT'S SIGNATURE: DATE:— <br /> PROPERTY/ <br /> ATE:PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Owner Agent <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign isregnired Time <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 envronmentaksie assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it i5 available and at dr Satre time R is <br /> provided to me or my representative. A �, <br /> TYPE OF SERVICE REQUESTED: (.( S/� — 2—c /��/q F�� <br /> COMMENTS: �A ✓ �G I�iF'I GCL /J vo� <br /> -Jl rD LC {�EC'E,I;V%ED <br /> AUG 14 2009 <br /> SAN JOAQUIN COUpNVIRONME T <br /> ACCEPTED BY: �(!t��I EMPLOYEE#: ®32-1 DAIEt ry i4 LYCI <br /> ASSIGNED TO: /..F�^/Q EMPLOYEE#: J ``42— DATE: a 144 t? <br /> Date Service Completed (if a eadycompleted): SERVICECODE: /48' PIE: �Q <br /> Fee Amount: (0 0-0 1 Amount Paid L b Payment Date q <br /> Payment Type (/ \' <br /> Invoice# Check# Z l 3 Recei By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />