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r <br /> 19255517888 Main Fax GETTLER RYAN INC 1' "1:26 a.m. 03-09-2007 2111 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'T'MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION -6�9�3 ggq35 <br /> OWNER/OPERATOR <br /> UNION 76 CHECK if BILLING ADD, RESSO <br /> FACILITY NAME UNION 76#6100 <br /> SITEADDRESS 25775S PATTERSON PASS TRACY 93292 <br /> Street 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 /> CITY Dublin STATE CA ZIP 94568 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 1 925) 551-7555 <br /> PHONE 82 ExT. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME Or MAILING ADDRESS 6747 Sierra Court, Suite J 2 9( s ) 551-7888 <br /> CITY Dublin STATE CA ZIP 94568 <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 I have prepared this application d th t ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an ED s. <br /> APPLICANT'S SIGNATURE: ` DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT R/MAN G ❑ OTHER AUTHORIZED AGENT lZ Agent for Owner <br /> If APPLICANT 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 COL:NTY 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 RETROFIT <br /> PAYMENT <br /> COMMENTS: <br /> REPLACE PRESSURIZED LINE LEAK DETECTOR FOR THE 87 MASTER TANK. MAR 0 9 200 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEP <br /> ACCEPTED BY: tA <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: IIVH EMPLOYEE#: DATE: —V7 <br /> Date Service Completed (if already completed): SERVICE CODE: (9$' P I E. <br /> Fee Amount: ? C45 Amount Paid s. Payment Date 6 <br /> Payment Type J ` Invoice# Check# L L0 et \ 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />