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19255517888 Main Fax GETTLER RYAN INC '^ 13:52 a.m. 05-23-2007 3/11 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FAC/ILIIT.Y�ID# SERVICE REQUEST# <br /> SERVICE STATION 00 5017 YJ� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> ARCO n <br /> FACILITY NAME ARCO-6080 <br /> SITE ADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number I Dir ion 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 /> Cmr Dublin STATE CA ZIP 64568 <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE 92 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Fm' <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME Or MAILING ADDRESS 6747 Sierra CourtSuite J FAx# <br /> ( 925 ) 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 and that th work be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED A ws. 2 I <br /> APPLICANT'S SIGNATURE: L DATE: /'0 "�/ -7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN GER ER AUTHORIZED AGENT IZ Agent for Owner <br /> If 4PPLICANT is not the BILLING PAS proo of aurization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:6h 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. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: <br /> REPLACE A POSITION SENSITIVE SENSOR (P/N 794380-323) <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: \ t �� EMPLOYEE#: GI DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (' P i E: Z 7� <br /> Fee Amount: • �-- 1 Amount Paid o2r � Payment Date <br /> Payment Type l S(ti Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />