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SAN JOA ,N COUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station ' ) <br /> OWNER/OPERATOR <br /> Paul Trahan CHECK if BILLING ADDRESS <br /> FACILITY NAME Gas LO <br /> SITE ADDRESS 7906 N EI Dorao <br /> Street Number n I StreetName CityC <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK IfSILLINGADDRESSPI <br /> BUSINESS NAME PHONE# ExT. <br /> Service Station Systems, Inc. 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 ACKtQWLEDGEMENT: 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 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:`1 t ; 't!_r 1 7/27/2016 <br /> � v�.l t•l.( YL.� t-t:..0 A-A_ L- DATE: <br /> PROPE RTY/BUSINESSOWNER Q OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT ✓❑ Compliance Officer <br /> IfAPPLiCANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AVTHORIZATION TO RELEASE INFgJLM.ATION: 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. ((`` PAYMENT <br /> TYPE OF SERVICE REQUESTED: UST inspection �`_�1 E-1 <br /> COMMENTS: FiliCEIVED <br /> JUL-2 9 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: --7 . : . ' <br /> ASSIGNED TO: EMPLOYEE#: DATE: —7 - � - <br /> Date Service Completed (if already completed): SERVICE CODE: I P1 E: <br /> Fee Amount: Amount Paid -:�,C1'E7 CC Payment Date <br /> Payment Type QAtxQ'i Invoice# Check# 57J(O() Received By: <br /> END 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />