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SAN JOA(2,,,N COUNTY ENVIRONMENTAL HEALTh .jEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />gas station <br />;I I, <br />OWNER I OPERATOR <br />Tesoro Corporation <br />CHECK If BILUNG ADDRESS <br />FACILITY NAME Shell (Tesoro) <br />HOME Or MAILING ADDRESS <br />680 Ave <br />SITE ADDRESS <br />FAX# <br />EMPLOYEE #: 7 7 <br />Quinn <br />-T <br />(408 <br />2448 W Kettlemn <br />Lane L <br />di CA 95242 <br />Zip 95112 <br />SERNCE CODE:(� % [, <br />P i E: �3 & S,:) <br />Sleet Nu bar <br />Direction <br />575-0) <br />Zw <br />Ira Name <br />citye <br />Invoice # <br />HOME or WAILING ADDRESS (If Different from She Address) <br />Check # <br />I Received By <br />Street Number <br />§treet Name <br />CITY <br />STATE zip <br />PHONE #1 ExT• <br />AP/^N`I <br />LAND USE APPLICATION # <br />t <br />PHONE 02 ExT <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />CC (k <br />L1C7(, <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Marty Weithman <br />F. <br />A rME At <br />CHECK II BILLING ADDRESS <br />BUSINESS NAME Service Station Systems, Inc. <br />PHONE# <br />EXT. <br />408 <br />213-6038 <br />HOME Or MAILING ADDRESS <br />680 Ave <br />ACCEPTED BY: .� it /�t1 -� - <br />v' 1 (r J <br />FAX# <br />EMPLOYEE #: 7 7 <br />Quinn <br />ASSIGNED TO: <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />Zip 95112 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 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: 2ti� �� �� _(_ DATE: 1/30/2014 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Q 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. <br />TYPE OF SERVICE REQUESTED: U ST iuspo6Eie" <br />F. <br />A rME At <br />COMMENTS: <br />03 241E <br />ACCEPTED BY: .� it /�t1 -� - <br />v' 1 (r J <br />EMPLOYEE #: 7 7 <br />DATE: 2 3 I t <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (If already completed): <br />SERNCE CODE:(� % [, <br />P i E: �3 & S,:) <br />Fee Amount: 3� 5 ____-- <br />Amount Pai <br />575-0) <br />Zw <br />Payment Date .21,311 <br />Payment Type <br />Invoice # <br />Check # <br />I Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />