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IN <br /> SAN JOAQI . COUNTY ENVIRONMENTAL HEALTHIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station tl j q7- s/i D v& 9'`7 <br /> OWNER/OPERATOR Chevron USA CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 1960 W 11 th St Tracy CA5376 <br /> Street Number ro cilv_ zip Cod* <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Nu,b, streot Na <br /> CITY STATE zip <br /> PHONE#1 Ext. APN* LAND USE APPucATION Ill <br /> ( ) �" 0),t7o t <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( 1 o �j> <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# Ext' <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS FAX# <br /> 680 Quinn Ave <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 1 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: ((LA-�; w�, �'- ��� ;�titi. .,� DATE: 11/25/2013 <br /> PROPERTY I BUSINESS OWNERD OPERATOR/MANAGER❑ OTHER AUTHORizEDAGENT ✓0 Compliance Officer <br /> IfAPPLICANT is not the AUWG PAR7Y.proof of authorization to sign Is required Title <br /> ALTHORLZATION TO RELEASE INFORMATION:When applicable, 1,the owner or operator of the property 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 inspection ! <br /> - R-ECE4urm <br /> COMMENTS: <br /> NOV 27 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M 3&11 DATE: // 27 13 <br /> ASSIGNED TO: ej9� EMPLOYEEC 2&4(, DATE: 1127 13 <br /> Date Service Completed (M already completed): SERVICE CODE: 9 g PIE: 2-3W <br /> Fee Amount: 3 7S2' Amount Paid <br /> 3-75. — Payment Date I( 2? 3 <br /> Payment Type Invoice# Check# 42-2-1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />