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SAN JOA(PN COUNTY ENVIRONMENTAL HEALTAEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station /� Ci5i C00 (Py �' OWNER /OPERATOR CHECK If ❑ Unocal 76 BILLING ADORESs FACILITY NAME Unocal 76 FAX# (408 SITEADDRESS 2701 March Lae, Stockto CA 95219 ZIP 95112 E TMRDEPARjhaF NFf.L ACCEPTED B StreetNumberri EMPLOYEE M ` DATE: 1 ASSIGNED TO: 6 44 � ,Q city Zlip Code HOME or MAILING ADDRESS (If Different from Site Address) Date Service Completed (M already completed): SERVICE CODE: Street Number street Name CITY STATE ZIP PHONE #1 EXT. APN S Payment Date LAND USE APPUCA71ON PHONE #2 EXT' ( 1 Invoice # I 130S DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR Marty Weithman CHECKNBILUNGADDRESSE] 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: 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:') �('� �,X—L.� .t� a Lti lL? DATE: 3/30/2012 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E) Compliance Officer 1fAPPLICANT is not the A!L-1NO P-AR7Y, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the rebase 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. kil TYPE OF SERVICE REQUESTED: UST inspection PP COMMENTS: Iq Ap,U4H �� ANS} ., E TMRDEPARjhaF NFf.L ACCEPTED B EMPLOYEE M ` DATE: 1 ASSIGNED TO: 6 44 � ,Q EMPLOYEE #: DATE; Date Service Completed (M already completed): SERVICE CODE: PIE: 2 3 Fee Amount: 0.0 Amount Paid 03-7 S', D () Payment Date Y(2 -112 -- Payment TypeLZ Invoice # I Check # 38 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11117/2003 �Ui�-