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SAN JOARN COUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station 3 Z <br /> OWNER/OPERATOR <br /> Chevron USA CHECK ifSILUNGADDREsso <br /> FACILITY NAME Chevron <br /> SITE ADDRESS 6633 Pacific Av ,Stockto ,CA 95207 <br /> Street Number CI <br /> tz Zip Cod* <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Neel Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN* LAND USE APPLICATION# <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Marty Weithman CHECKNBILLING ADDRESS <br /> � <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# Exr. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS 680 Quinn Ave FAx# <br /> (408 j 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:nl r� c L��;�, � ✓►Lc,iu�/ DATE. 12/27/2012 <br /> PROPERTY/BUSINESS OwNERQ OPERATOR/MANAGER❑ OTHERAUTHORIZEDAGENT ✓Q Compliance Officer <br /> If,1PPLICANT is not the B/LI M PAR7Y,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 /> TYPE OF SERVICE REQUESTED: UST inspection <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: Pi <br /> Fee Amount; -- <br /> Amount PalPayor t Date 3� �� �✓ <br /> Payment Type Invoice# Check# dr�d Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Qv' <br />