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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or PropertyFACILITY <br />ID # SERVICE REQUEST # <br />gas station <br />v <br />�j 7,?OWNER <br />/ OPERATOR <br />CHECKtfBILuNoADOREss® <br />Valero Energy Corp. <br />HOME or MAILING ADDRESS 680 Quinn Ave <br />FACILITY NAME Valero (#3641) <br />FAX# <br />(408 <br />SITE ADDRESS 1210 E Hamme <br />Lane, St <br />kton CA 95210 <br />ZIP 95112 <br />EMPLOYEE #: <br />Street Number <br />D roStmetNomec <br />d (H already completed): <br />ty <br />HOME or MAILING ADDRESS Of Different from Site Address) <br />Fee Amount: <br />3 -;,5;, , <br />Amount Paid <br />Street Number <br />tne! Na <br />CITY <br />STATE zip <br />PHONE #1 EXT. <br />APN * <br />LAND USE APPLICATION <br />Check # <br />Received By: <br />PHONE #2 EXT. <br />( l <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />Marty Weithman <br />CHECK If BILLING ADDRESSP1 <br />BusihEss NAME Able Maintenance, Inc <br />PHONE# <br />408 <br />EXT. <br />213-6038 <br />HOME or MAILING ADDRESS 680 Quinn Ave <br />FAX# <br />(408 <br />) 213-6026 <br />CITY San Jose <br />STATE CA <br />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: ��.(;tt� DAT", 6/2512012 <br />PROPERTY/ BUSINESS OWNERC) OPERATOR/MANAGER ❑ OTHERAuTnoRIZEDAGENT D Compliance Officer <br />IfAPPLICANT is not the BILLING PARTY proof of authorization t0 sign is required Title <br />AUTHORIZATION 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: piping inspection <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE M J <br />t� <br />DATE S ,..o._ 2S 1 <br />ASsiGNED TO: <br />EMPLOYEE #: <br />DATE: ZS <br />Date Service CI <br />d (H already completed): <br />SERVICE CODE: f (� <br />PIE: - <br />Fee Amount: <br />3 -;,5;, , <br />Amount Paid <br />-7S'_ C Z> <br />Payment Date <br />1 , <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48.02-025 ��t/ 1` I ( PAY M E ST SR FORM (Golden Rod) <br />REVISED 11/17/2D03 PECEIVED <br />JUN 2 5 2012 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DE:FARTMENT <br />