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10255517888 Main Fax GETTLER RYAN INC 11 54 25 a m 12 20 2006 2111 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION <br /> OWNER I OPERATOR <br /> ARCO CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO <br /> SITE ADDRESS �r N CALIFORNIA STOCKTON <br /> 3212 95204 <br /> Sheet Number Street Name city <br /> ZipCode <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 /> 7. <br /> ( 925 ) 551-7555 ( 2.> - 5 Z.i - t • I <br /> PHONE#1 EXT. BOS DISTRICTLOCATION CODE <br /> _ <br /> f ) 1— < t <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> LIDDY MCKENZIE CHECK If BILLING ADDRESS m <br /> BUSINESS NAME PHONE# EzT. <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME or MAILING ADDRESS FAx# <br /> 6747 Sierra Court, Suite J ( 925 ) 551-7888 <br /> CITY 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 /> 1 also certify that I have prepared this application and that the wor to be performed will be done in accordance with all SAN JOAQUIN <br /> CouNTY Ordinance Codes,Standards,STATE and FrDERA la <br /> APPLICANT'S SIGNATURE: DATE: 1� 7-0/0 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/ NA ❑ 01"ER AUTHORIZED AGENT IZ Permit Expeditor <br /> IfAPPLICANT is not the BILLING PARTE proof of authorization to sign is required Title <br /> AUTHORIZATION "r0 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: <br /> COMMENTS: <br /> REPLACE 91 TURBINE SENSOR (PART NO. 794380-323). <br /> REPLACE UDC SENSOR FOR DISPENSER 1 & 2. <br /> SAN JOF+C�JIN CCUN' <br /> ENVIRONtJtENTAL <br /> IAEAUTH DEP.ARTNIENT <br /> ACCEPTED BY: `t F t .A �} EMPLOYEE#: J DATE: f 2-12. <br /> ASSIGNED TO: � 4 EMPLOYEE#: 1-t, S S DATE: -2 /Z C.l <br /> Date Service Completed (if already Completed): SERVICE CODE: I �, PIE: <br /> 3 i <br /> Fee Amount:-<A a95. L-0 Amount Paid a o s, 6b Payment Date \ZI 10 <br /> Payment Type v ` S Invoice# a e r# u Received By: �G <br /> c. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />