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'10- SAN JOAN COUNTY ENVIRONMENTAL HEALTIREPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station BUSINESS NAME Service Station Systems, Inc. b O OWNER / OPERATOR CHECKIfBII,LUNOADDRESS® Darren Eppler FAx# (408 FACILITY NAME Unocal 76 CITY San Jose SITE ADDRESS 2701 March Lae, Stockto CA 95219 ACCEPTED BY: EMPLOYEE #: streef Number roStreet me Q11tv ZipCode HOME or MAILING ADDRESS (if Different from Site Address) SERVICE CODE: Street Number Street Name CITY STATE Zip PHONE M EXT. APN # Invoice # LAND USE APPLICATION # PHONE#2 EXT. Received By: SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Marty Weithman AY!ENT CHECK If BILLING ADDRESStJ BUSINESS NAME Service Station Systems, Inc. PHONE# 408 EXT. 213-6038 HOME or MAILING ADDRESS 680 Quinn Ave FAx# (408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this fon-n. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:1 i (a L U,t. C t • �1 k C L -t- 0,t t A t L' DATE: 11/26/2012 PROPERTY/ BUSINESS OWNERQ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ✓0 Compliance Officer JfAPPLIC&T is not the BILLING P,4RTY, proof of authorization to sign is required Title AUTAORIZATjON TO RELLA5E ILi ffl MATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: UST inspection AY!ENT COMMENTS: NOV 2 9 2012 SAN J04ourN cou" •""' 'RGN-4EN'TAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: i'v ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: Fee Amount: 413aS ` Amount Paid 0,D Payment Date It �4 Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 f20 �-/