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0 <br /> SAN JOAt2UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station � "� S10U� <br /> OWNER/OPERATOR l� <br /> RADC Enterprises CHECK ifIBILUNGADDRESS❑ <br /> FACILITYNAMETracy Blvd Shell and Mini Mart <br /> SITE ADDRESS 3725 N Tracy Bd,Tracy A 95376 Str"t Nome <br /> city <br /> Street Number <br /> — I Zip Code <br /> HOME or MAILING ADDRESS (if Differant from Site Address) 1040 N Benson Ave <br /> Steel Number teal Name <br /> CITY Upland STATE CA ZIP 91786 <br /> PHONE#1 ExT. APN* LAND USE APPLICATION <br /> ( 909-594-4728 3 0 <br /> PHONE#2 Err. SOS DISTRICT LOCAmoN CODE <br /> ( 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS <br /> a <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# EXT. <br /> 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 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 /> I also certify that l 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:7l� E, I �L • �L=t i C�t l 1 Lyc DATE: 4/2/2012 <br /> PROPERTY/BUSINESS OwNER❑ OPERATOR/MANAGER❑ OTIIERAUTHORIZED AGENT O Compliance Officer <br /> IfAPPL/CANT is not the BILLING Pa7Y.proof of authorization to 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 /> TYPEOFSERVICEREQUESTED: UST inspection PP *Jell <br /> COMMENTS: P O ^O{ <br /> QU pS- <br /> SATiE��R�EM R ME� <br /> N��TH <br /> ACCEPTED B , EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (f alreac4 compieted): SERVICE CODE: l P i E: 2 <br /> Fee Amount & Amount Paid �; �, Payment Date 3 7 <br /> s <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />