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' . SAN JOAMN COUNTY ENVIRONMENTAL HEALAEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station > Z LI/ I OWNER /OPERATOR PHONE III Darren Eppler CHECK if BIL UNGADDRE53❑ FACILITY NAME 213-6038 HOME or MAILING ADDRESS Unocal FAX HEALTH DEPARTMENT SITE ADDRESS 2701 W Marchane, Stoc ton CA 95219 ) 213-6026 CITY San Jose STATE CA ZIP 95112 Street Number Date Service Completed (H already completed): SERVICE CODE: Cl tm Zip Cod* HOME or MAILING ADDRESS (If Different from Site Address) �' �' —� Payment Date Street Number Stroot NAM* CITY STATE zip PHONE #1 EXT' APN 9 LAND USE APPUCA71ON # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Marty Weithman CHECKIfBILLING ADDRESS � BUSINESS NAME Service Station Systems, Inc. PHONE III EXT, SAN JOAQUGN COUNTY 408 213-6038 HOME or MAILING ADDRESS FAX HEALTH DEPARTMENT 680 Quinn Ave (408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNOWLEDGEMENT: 1, 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 form. 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: "� !f Gz c t ti L ' �I L t t i t ` ,L k-� DATE: 6/12/2012 PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AIiTHORiZEDAGENT D Compliance Officer 1jAPPLICANT is not the BILLING PARTY proof ojauthorization to sign is required Title AVTHORIZAiTION TO RELEASE INFORMATION: When applicable,1, 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 COMMENTS: JUN 14 2012 SAN JOAQUGN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (H already completed): SERVICE CODE: P I E� Fee Amount: 7 Amount Paid �' �' —� Payment Date Payment Type Invoice # Received By: 7! EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003