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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gasoline Service Station <br /> OWNER/OPERATOR <br /> Tesoro Refining& Marketing CHECK If BILLING ADORESS❑ <br /> FACILITY NAME <br /> Chevron#98264 <br /> SITE ADDRESS 3775Tracy Blvd. Tracy 95376 <br /> Street Num ber Direction Street Name Cit Zi Cole <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> same as above <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 1 212-17-28 <br /> PHONE#2 EZT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Eric Janzen CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# 707 293-298b <br /> Able Maintenance, Inc. If I <br /> HOME or MAILING ADDRESS FAX# 707 545-5515 <br /> 3224 Regional Parkway I ) <br /> CITY Santa Rosa CA 95403 STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <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 /> 1 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 and FEDRIAL laws. <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWNER 5BiLLING <br /> 4Rproof <br /> ❑ OTHER AUTHORIZED AGENT q(I Code Compliance Officer <br /> J,fAPPL/CANT is not the gjauthorization to sign is required/ Z Title <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 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. <br /> TYPE OF SERVICE REQUESTED: S C to t r <br /> COMMENTS: <br /> RECEIVED <br /> FEB 13 2012 <br /> ` SAN JOAQUIN COUNTY - <br /> ENVIRONMENTAL <br /> HEALTH DM*RMJNr <br /> ACCEPTED BY: OC_L V E f _// EMPLOYEE#: O 3 24 DATE. �3 �•L. <br /> ASSIGNED TO: —y—��, _1G p�-T\ EMPLOYEE#: �(e tf DATE: i3l Z <br /> Date Service Completed (iff�already Completed): SERVICE CODE: �G� L P/E: ;Z-?I)6 <br /> Fee Amount: . 3%S 1,0 Amount Paid p-V Payment Date /5 <br /> Payment Type ✓ Invoice# Check# 6 aC� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />