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f <br /> SAN JOA,, IN COUNTY ENVIRONMENTAL HEALTRIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station S o �00 6 3 C� <br /> OWNER/OPERATOR <br /> RADC Enterprises CHECK IfBILLING ADDRESS❑ <br /> FACILITY NAME Shell <br /> SITE ADDRESS 3725 N Tracy B d,Tracy ty <br /> Street Number Ci <br /> HOME or MAILING ADDRESS (if Different from Site Address) 1040 N Benson Ave <br /> Street Number Street Name <br /> CITY Upland STATE CA zip 91786 <br /> PHONE M Exr. APN* LAND USE APPLICATION# <br /> ( 909-1394-4728 <br /> PHONE 02 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS ✓� <br /> BUSINESS NAM'Service Station Systems, Inc. PHONE# EXT, <br /> 408 213-6038 <br /> HOME Or MAILING ADDRESS FAX# <br /> 680 Quinn Ave <br /> (408 j 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 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 /> 1 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: I�Q�a,L i�.i�, d V-t, (i i, 1 ' DATE: 9/12/2011 <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTNERAUTHORIZEDAGENT Q Compliance Officer <br /> IfAPPLICANT is not the BILL/NG PARTY proof of authorization to sign is required Tits <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:UST inspection C�sT ,�1 %'oGi l PA <br /> ED <br /> COMMENTS: <br /> SEP 13 2011 <br /> SAN,ra*QutN courm <br /> E WH DNEpkRTME1IT <br /> REAL <br /> ACCEPTED BY: LPEMPLOYEE#: DATE: h/ <br /> ASSIGNED TO: EMPLOYEE#: &7 DATE: 3 <br /> Date Service Completed (H already completed): SERVICE CODE: I i Pr1E-.L50g <br /> Fee Amount: .3.7S--:- Amount Paid t37 S. o Payment Date l 3 <br /> Payment Type Invoice# Check# 3 4oOU Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />