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SAN JO IN COUNTY ENVIRONMENTAL HEAL EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID II SERVICE REQUEST# <br /> gas station <br /> OWNER/OPERATOR <br /> Chevron USA CHECK Iff UJW Aoo <br /> FmXffY NAME Chevron <br /> SITE ADDRESS 6633 Pacific Av nue,Stoc ton CA 95207 <br /> rDirwilan <br /> HOME or Ir wwo ADDRESS (if Different from Site Addresa) PO Box Q PO Box Q <br /> Str"tNumtor <br /> CITY Concord STATE CA ZIP 94524 <br /> PHONE 91 En APN I LAND USE APPLICA71ON <br /> ( 916-11152-2244 <br /> PI NE 02 EXT• SOS DISTXT L CATION CODE <br /> ( 1 <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUEsTOR Marty Weithman CHECKNBlLuwaAooREss <br /> BUSINESS NAME Service Station Systems, Inc. PNONE# Exr• <br /> 408 213-6038 <br /> HOME orAILINOADDRESS 680 Quinn Ave FAX# <br /> (408 ) 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> R,LUNG ACKNQWLEDG TIENT: 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 we 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 SAH JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2/17/12/8/09 <br /> PROPERTY/BUSINESS OwNER❑ OPERATOR/MANAGER❑ OTHERAUTHORIZEDAGmE] Compliance Officer <br /> ifAPPLICANT is not the BILLING P.f=proof of authorization to sign is required Title <br /> AU1HORIZA1I0 TO,RELEASE 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 REouEsTED:UST inspection <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE C DAZE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): CODE: P I E., <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />