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SAN JOAQUIAk)UNTY ENVIRONMENTAL HEALTH&ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Service Station �L Sk-oo ggpg-o <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Arco <br /> FACILITY NAME Arco Service Station #9600 <br /> SITE ADDRESSStockton 95205 <br /> 1250 North Wilson Way <br /> Streel Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court, Suite J <br /> Street Number Street Name <br /> CITYDublin <br /> STATE CA ZIP 94568 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> 1 925 ) 551-7555 <br /> PHONE#2 Exr. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Scott Polston CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Exr. <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME Or MAILING ADDRESS6747 Sierra Court Suite FAX# <br /> Court, J ( 92s ) 551-7888 <br /> CIT`' Dublin STATE CA ZIP 94568 <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 I have prepared this applic on If t t the Work a med will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S E E s <br /> Yl <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT Permit Expeditor <br /> IfAPPLICANT 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. ,/� ,,- D ,, T <br /> TYPE OF SERVICE REQUESTED: a-ST 0—�'r-46 F--t T— RECEIVE <br /> COMMENTS: NOV 9 2005 <br /> SAN JOAQUIN <br /> TM <br /> RONMENTAL <br /> ,t HEALTH DEPARTMENT <br /> ACCEPTED BY: OL-E V C--,4A " EMPLOYEE#: -�'3 Zr DATE. 11 /gldI,;-- <br /> ASSIGNEDTO: Wt(�O�J EMPLOYEE#: CfgO3 DATE: tt [ 'T(Os— <br /> Date Service Completed (if already completed): SERVICE CODE: f P/'E: 23 <br /> Fee Amount:- d4,FrLU' Amount Paid ��-j ! O l7 Payment Date <br /> Payment Type Invoice# Check# a-�(o Received By: �� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />