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SAN J UIN COUNTY ENVIRONMENTAL HEA10 DEPARTMENT <br />SERVICE QUEST <br />Type of Business or Property FACILITY ID # <br />gas station SERVICE REQUEST <br />OWNER / OPERATOR <br />Miariana CHECK ifBn -WA20M <br />FACILITY NAME Valero <br />SITE ADDRESS 1001 E Yosemit Ave, Mai iteca CA 95336 <br />stnst Number_ <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY <br />PHONE #t <br />( 1 <br />PHONE #2 <br />REQUESTOR <br />Marty Weithman <br />Exr. <br />BUSINESS NAME Service Station Systems, Inc. <br />HOME Or MAILING ADDRESS <br />680 Quinn Ave <br />STATE Zip <br />LAND USE APPucAnoN <br />III <br />21 <br />CODE <br />CHECK If AL6LftQAQDRCS§ El <br />CITY San Jose 1— ) 213-6026 <br />STATE CA ZIP 95112 <br />AILLIN9 ACM V1,E2F IVT: 1, the undersigned property or business owner, operator or authorized agent of same, <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 />I also certify that I 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:II CI -C : i� c -If !"'' DATE: 6/16/2014 <br />PROPERTY/ BUSINESS OwNERC OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Q Compliance Officer <br />If APPLICANT is not the BILLING PARTY proof Of authorization to sign is required Title <br />AUTHORIZAIJON T(3 ULLME Iff-QR r A LQN, , When applicable1, the owner or operator of the property �•�j,�„• p party 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: UST <br />COMMENTS: <br />ACCEPTED BY: <br />ASSIGNED To: <br />Date Service Completed {if already completely <br />Fee Amount: Amount Paid <br />EMPLOYEE M DATE: <br />EMPLOYEE M DATE: <br />SERviC€ CobE: EPIE: <br />Payment Date <br />Payment Type I Invoice # Check <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Received By: <br />SR FORM (Golden Rod) <br />