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e <br /> SAN JO.. -JIN COUNTY ENVIROWEN—AL HEAL._. .DEPARTMENT <br /> . e f, - <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station <br /> OWNER/OPERATOR <br /> Tesoro Corporation CHECK IfBILUNGADDRESS❑ <br /> FACILITY NAME Shell(Tesoro) <br /> SITE ADDRESS 2448 Kettleman Lane, Lod <br /> Sleet Number n s e cityI e <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3450 S 344th Way <br /> Street Number Street Na <br /> CITY Auburn STATE WA ZIP 98001 <br /> PHONE#I Ext. APN 9 LAND USE APPLICATION M <br /> ( 253496-8700 <br /> PHONE 01 En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK It BILLING ADDRESS <br /> BUSINESS NAME Able Maintenance, Inc PHONE# *• <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 l 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: l�L( L L c Z � ��—f ttic,,Lt-if-L L-: DATE 6/8/2011 <br /> PROPERTY/BusINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Compliance Officer <br /> lfAPPLICANT 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 re <br /> TYPE OF SERVICE REQUESTED: UST inspection\ PAYMENT <br /> COMMENTS: RECEIVED <br /> JUN 1.9 2011 <br /> SAN JOAQUiN CouNTy <br /> ENVIRONMENTAL <br /> orr,,Pn.�:.T <br /> ACCEPTED BY: EMPLOYEE#: GCS DATE: <br /> ASSIGNED TO: C AEMPLOYEE#: J �. DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE; CG <br /> Fee Amount:, to Amount Paid i Payment Date <br /> Payment Type t/ Invoice# Check# 3 5 S Received By: 1_. <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />