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SAN JOIN COUNTY ENVIRONMENTAL REALTODEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gas station 3.7 7 200 � VO <br /> OWNER/OPERATOR <br /> RADC Enterprises CHECKffBILUNGAOORESSc] <br /> FACILITY NAME Shell <br /> SITE ADDRESS 2375 W Grant Tne <br /> Street Number a city <br /> HOME or MAILING ADDRESS (if Different from Site Address) PO Box 3069 <br /> Street Number Street Name <br /> CITY Houston STATE TX Zip 77253 <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> ( 909-194-4728 <br /> PHONE#2 Ext. BOS DISTRICT <br /> LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Marty Weithman CHECK)f BILuNGADDRESS� <br /> BUSINESS NAME Service Station Systems, Inc. PHONE# EXT. <br /> 408 213-6038 <br /> HOME or MAILING ADDRESS FAx# <br /> 680 Quinn Ave <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 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: l��(�u%(�ti�. U . 11lt.E'�c 1, DATE: 7/6/2011 <br /> PROPERTYIBUSINESS OwNERM OPERATOR/MANAGER❑ OMERAUTHORIZED AGENT ✓] Compliance Officer <br /> 1fAPPL1CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION 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. N� <br /> TYPE OFSERVICE REQUESTED:UST inspection —T— 1 ��t` t CSN <br /> COMMENTS: <br /> H�y.1-1N <br /> ACCEPTED BY: F—( e-4- EMPLOYEE#: j 2 DATE: -7/7/t/ <br /> ` <br /> ASSIGNED TO: I EMPLOYEE M L'(t (� DATE: '7 /-7 / <br /> t 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount:; S _CUAmount Paid 3�(o- C Payment Date _71-710 <br /> Payment Type invoice# Check# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />