Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # � � SERVICE CD � # <br /> gas station <br /> OWNER / OPERATOR <br /> Chevron CHECK If 13ILLING<Ap[1RESS <br /> FACILITY NAME <br /> Chevron #208117 <br /> SITE ADDRESS 755 S Tracy Blv , Tracy C 95376 <br /> Street Number Direction 61041ame city ZloCod <br /> HOMEor MAILING ADDRESS (If Dlfferenl from Site. Address) Iq ! A��/M�/° <br /> Street Number lteelNe ,rIC' • T <br /> CITY STATE ZIP %,Z'VP® <br /> PHONE #t Ent APN # LANuUsi APPLICAMON # S O8 ?0 <br /> 1 1 ,� ✓o V 19 <br /> PHONE #2 Exr. faOS D1SVRICTI ... ... NME <br /> CONTRACTOR % SERVICE REQUESTOR 1�1 <br /> REQUESTOR Marty Weithman axecKif. eiLuNaAobmssEl <br /> BUSINEss NAME PHONE# Em <br /> Service Station Systems, Inc . 408 213-6038 <br /> HOME or MAILING ADDRESS FAX # <br /> 680 Quinn Ave (408 y 213-6026 <br /> CITY San Jose STATE CA ZIP 95112 <br /> BILKING ACKNOWLEDGEMENT: 1 , the undersigned property or business owner, operator or authorized 'agept 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 I 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 S] GNATU �RE : vwt"\j • fu ry t.f.0-e�� DATE: 518/2019 <br /> PROPERTY IBUSINESS OWNERC OPERATOR / MANAGER ❑ OTHER AUTNORnEDAGENT Compliance Officer <br /> lfAPPLICANT is not:1he.B1LLINGPARTY, .propf of authorization to siin is required Thle <br /> AUTHORIZATION TO, RELEASE INFORMATION: When applicable, I , the owner or .operstor of the property located at the: <br /> above site address, hereby "authorize the release of :any and all results, geotechnical data and/or envronmental/si#.e assessment <br /> information to the SAN 10AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as ii is available and .at the same time it iS <br /> provided to me or my representative , <br /> f ' <br /> TYPE OF SERVICE REQUESTED : UST inspection f <br /> COMMENTS : <br /> Wit AY 0 V <br /> ENVIRONMENT L HEALTH <br /> DEPARTN ENT <br /> ACCEPTED BY; EMPLOYEE #: f DATE; C , <br /> ASSIGNED TO: EMPLOYEE M / DATE: C J_ <br /> Date Service Completed (If alrea completed);. . SERVICE CODE . P4 Er: <br /> Fee Amount; Am .untPai. S�• d � Payment Date $- � <br /> Payment Type /q Invoice # Check # 47 2 7,3 R0ei ed 13y : <br /> EHD 48-02.025 SR FORM (Golle.n Rod) <br /> REVISED Iill 7/2003 <br />