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SAN JOAsk COUNTY ENVIRONMENTAL HEALTALARTMENT SERVICE REQUEST Type of Business or Property gas station FACILITY ID # SERVICE REQUEST # cS12C�0 (o S3 22 - OWNER / OPERATOR Valero Energy Corporation CHECK itBILuNGADOREssEl FACILITY NAME Valero #3641 EXT. 213-6038 SITE ADDRESS 1210 E Hamme Street Number Lane Sto kton CA 95210 ) 213-6026 city STATE CA HOME or MAILING ADDRESS (If Different from Site Address) SGeei Number street Name CITY STATE ZIP PHONE M ExT• APN * LAND USE APPLICATION PHONE #2 ExT• P i E: "Z BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Marty Weithman "� CHECK HBILLING ADDRESS � BUSINESS NAME Service Station Systems, Inc. RECEIVED PHONE# 408 EXT. 213-6038 HOME orMAH.INaADDRESS 680 Quinn Ave JUL 1 6 2012 -e" 'XI IN COUNTY HLkL.TH DEPART E- ff 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 I 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: ��, c'-t.t-u t-�, L_0 -t:0 DATE.: 6/29/2012 PROPERTY / BUSINESS OWNERL OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT Q Compliance Officer 1fAPPLlCANT is not the BILLING PARTY. 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 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. r,wvnAFNT TYPE OF SERVICE REQUESTED: "� RECEIVED COMMENTS: u Q v JUL 1 6 2012 -e" 'XI IN COUNTY HLkL.TH DEPART E- ff ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE: DATE: Date Service Completed (H already completed): SERVICE CODE: P i E: "Z Fee Amount: Amount Paid % S , Cf) Payment Date Payment Type Invoice # Check Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003