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SAN JOAQuIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station5-/;;1i <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> Tesoro Refining and Marketing Copany <br /> FACILITY NAME Shell (Tesoro) <br /> SITE ADDRESS 2448 W Kettlemn Lane, di CA 95242 <br /> Street Number Direction Name city <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3450 South 344th Way <br /> Street Number Street N&MO <br /> CITY Auburn STATE WA Zip 98001 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION If <br /> ( 2538)968700 <br /> PHONE#Z ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS rl <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# ExT. <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: 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 /> 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: ,� .LiL 'v .�)'v:-�t�C�� t �' DATE: 8/27/2012 <br /> PROPERT)'/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AtI7HORIZEDAGENT❑ 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. Pr <br /> TYPE OF SERVICE REQUESTED: UST inspection u1ECT''^,rr_ <br /> COMMENTS: AUGI, C s <br /> Lt,:,; <br /> SAN JOAQUIN COUNT) <br /> ENVIHOMENTAL <br /> HEALTH DEPARTMENT' <br /> ACCEPTED BY: 6ww <br /> EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already complet ): SERVICE CODE: <br /> PIE: <br /> Fee Amount: Amount Paid �-7 CJS Payment Date ZS /Z <br /> Payment Type Invoice# Check# Re elved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />