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SAN JOAQ%COUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station <br /> OWNER/OPERATOR <br /> Chevron CHECK If BILLING ADDRESS® <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 6633 Pacific Av ,Stockto CA 95207 <br /> Street Number rection StreetName C 1 Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Streel.Name <br /> CITY STATE zip <br /> PHONE#I ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK If BILLING ADDRESS <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 ACKNOWLEDGEMENT: I, 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 I 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: DArE: 11/26/2012 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT Q Compliance Officer <br /> If APPLICANT is not the BILLtNGPARTY,proof of authorization to sign is required Title <br /> AUS)JORI ATION TO RELEAH INEg MATION: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 inspection PAYMENT <br /> COMMENTS: <br /> NOV 2 9 2012 <br /> SAN JOAQUIN(- <br /> EWRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: p►E: <br /> Fee Amount: 5 av Amount Pai 376.DD Payment I ate <br /> Payment Type Invoice# Check# 396 9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 f2v <br />