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SAN JOA V COUNTY ENVIRONMENTAL HEAL EPARTMENT C <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station I �`'0 o 3'13(1 S 900��c��� C1 <br /> OWNER/OPERATOR <br /> Valero Energy CHECK ifSwNGADDRESS <br /> � <br /> FACILITY NAME Valero 3641 <br /> SITE ADDRESS 1210 E Hamme Lane, St kton CA 95210 <br /> Street Number Name c1tv 77z,.Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 ExT. APN I LAND USE APPUCA noN# <br /> ( 1 ! l _ o3c PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> I 1 e7o 01 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REAUES7OR <br /> Marty Weithman CHECK If BILUNGADDRESS� <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# EXT. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAx# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILLING ACKN�)t WLEDGEMENT: 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: DATE: 9/3/2013 <br /> PROPERTY/BUSINESS OWNERL OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENTO Compliance Officer <br /> IfAPPL1C4xT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 itjspectivn rte, ti <br /> COMMENTS: <br /> RECE- ED <br /> SEP 0 6 203 <br /> SAN JOAQUiN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: ('t EMPLOYEE M -2-670 <br /> I f: �, <br /> ASSIGNED TO: �' t C;C , EMPLOYEE M e- C, 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: 4302 - Amount Paid 3 7S"'® Payment Date 9 <br /> Payment Type Invoice# Check# L//7'1 Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />