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` SAN JO IN COUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> gas stationA--b'0'5'9 3-71 <br /> OWNER/OPERATOR <br /> Chevron USA CNtCK1fiBILJ <br /> FACILITY WE Chevron <br /> SITE ADDRESS 6633 Pacific Av nue,Stoc ton CA 95207 <br /> Stmet Numbet C <br /> ix rJR 9292 <br /> HOME or MAILING ADDRESS (If Different from Sits Address) PO Box QP <br /> O Box Q <br /> StreetNumber limit NMI <br /> CITY Concord STATE CA zip 94524 <br /> PHONE#1 Ext. APN if LAND USE APPLICATION It <br /> ( 916452-2244 7- q(()—q8' <br /> P <br /> ( — <br /> p #2 En. BOS DismT LOCATION C E <br /> ( l <br /> 2-- <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUEST®R <br /> Marty Weithman CHECK NA SS ✓ <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# Exr• <br /> 408 213-6038 <br /> HOME Or MAILING ADDRESS FAX# <br /> 680 Quinn Ave <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA YIP 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 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: " t' ; t DATE: 2/17/12/8/09 <br /> PROPERTY/BusxNEssO OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT ✓0 Compliance Officer <br /> lfAPPmcANT is not the BaMffii PrIRTY.proof of authorization to sign is required rine <br /> AM=&&TJON TO E&KAH INFORMATION: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 i't ' m) <br /> COMMENTS: <br /> JOf\ COON -y <br /> AL <br /> 4-tE�L�N UL=1'I�RC�tE 'T <br /> ACCEPTED BY: O _i QS(AA- EmPLOYEE III: DATE: (� ( 0 <br /> ASSIGNED TO: EIMPLOYEE : DATE: ( C O <br /> Date Service Completed (H already completed): CODE: fP 1 E: <br /> Pee Amount: 3 c�- - Amount Paid _ Payment Date t <br /> Payment Type Z Invoice Check ii Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />