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SAN JG.-,tUIN COUNTY ENVIRONMENTAL HEAL.. DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station <br /> OWNER/OPERATOR <br /> Tesoro Corporation CHECK IfSILUNGADDRESS <br /> � <br /> FACILITY NAME Shell(Tesoro) <br /> SITE ADDRESS 2448 Kettleman Lane, Lod <br /> Street Number e <br /> city Zip C900 <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3450S 344th Way <br /> Steel NumberStreet Name <br /> CITY Auburn STATE WA ZIP 98001 <br /> PHONE#1 1 Er. APN 9 LAND USE APPLICATION N <br /> ( 253496-8700 <br /> PHONE 02 En. SOS DISTRICT <br /> LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK HBILUNGADD <br /> ILS <br /> � <br /> BUSINESS NAME Able Maintenance, 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: I, 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 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: L C CiLt,1 -- DATE: 6/8/2011 <br /> � (. � --{�X�L-L L i..Et�L-V <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[) Compliance Officer <br /> 1fAPPL1CANT is not the BILLING PART1,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. <br /> TYPE OF SERVICE REQUESTED: UST inspection <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: 7 P i E; <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />