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` SAN JOIN COUNTY ENVIROIt;ENTAL HEAL&EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station R-3 If <br /> OWNER/OPERATOR <br /> Chevron USA CNECKifBILUNGAODRESScl <br /> FACILITY NAME Chevron USA <br /> SITE ADDRESS 6633 Pacific Av StocktonCA 95207 <br /> tnet Number e e I ON Cgd, <br /> HOME or MAILING ADDRESS (If Different from Ske Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 ExT. APN# LAND USE APPLICATION N <br /> PHONE#T Enr. 608 DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECK If BILLINGADDRESS� <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: 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: /4wat z U . DATE: 1/199/2011 <br /> PROPERTY/BUSINESS OWNERCI OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT Compliance Officer <br /> 1fAPPLICANT is not the BILLING PARTY,proof of authorization to sigh is required Title <br /> AU1HORIZAT1gN 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. lLkdaF-7-xq ,F (—T— <br /> TYPE OF SERVICE REQUESTED:UST inspection e ` <br /> COMMENTS: <br /> ,AN 20 2©11 JAN 40'-2011 <br /> pU,N CUNN <br /> SAN JO RONM� ONMENTAL HEAL M <br /> HATH p1rPP� RMIT/SERVICES <br /> ACCEPTED BY: O L U ( EMPLOYEE M G3 Z4 DATE: 1 f <br /> ASSIGNED TO: Get CS EMPLOYEE M ( 7j DATE: j It <br /> Date Service Completed (H already completed): SERVICE CODE: ci r;. Pi <br /> Fee Amount: iF,�, �, Amount Paid ?J Payment Date \ a O \ <br /> Payment Type Invoice# Check# 2 y 6'1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />