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SAN JOA* COUNTY ENVIRONMENTAL HEALTIOEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station/� _ l i;�? �2 + C,— OWNER i OPERATOR ASSIGNED TO: fsLh� �ij% Miariana } 213-6026 CHECK If BILUNO ADDRESS FACILITY ]DAME Valero ZIP 95112 �' SERVICE CODE: 1, � � PIE: � Fee Amount: r; "{-�- Amount Palo SITE ADDRESS 1001 E YosemitAve, Ma teca CA 95336 Invoice # Check # 3 (o b Received By: Street Number Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number StreeL Ngme CITY STATE zip PHONE #1 Ev. APN 0 LAND USE APPLICATION # 22 � J �T PHONE#2 EXT. BOS DISTRICT LOCATION90DE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Marty Weithman -11 474FAI REC T CHECK If BILLINGADDRESS BUSINESS NAME Service Station Systems, Inc. ACCEPTED BY: �C, �2 v PHONE# 408 EXT. 213-6038 HOME or MAILING ADDRESS 680 Quinn Ave ASSIGNED TO: fsLh� �ij% FAX# (408 } 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNQWLgD9EMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that alt 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: ` I (C,�C,U- L, �' '- f �i (l-Ctf -c.L� DATE: 6/16/2014 PROPERTY/ BUSINESS OWNERO OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT✓Q Compliance Officer If,'PPLICANT is not the BILUIVG P.4RTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATJON: 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. PA t,.._ TYPE OF SERVICE REQUESTED: UST inspection -11 474FAI REC T COMMENTS:IN 8 EJyy1 QUmy ACCEPTED BY: �C, �2 v EMPLOYEE #: DATE: b t ' QCs ASSIGNED TO: fsLh� �ij% EMPLOYEE #: DATE: Date Service Completed (it already completed): �' SERVICE CODE: 1, � � PIE: � Fee Amount: r; "{-�- Amount Palo 3 '7S Da Payment bate /4, Payment Type Invoice # Check # 3 (o b Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003