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19255517888 Main Fax GETTLER RYAN INC 11,42 19 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/OPERATOR <br /> ARCO CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO <br /> SITE ADDRESS E LOUISE AVE LATHROP 95330 <br /> 85 Street Number Direction I me city i e <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court, Suite J <br /> Street NumMr Street Name <br /> CITY Dublin STATE CA ZIP 94568 <br /> PHONE#1 EXT. APN* LAND USE APPLICATION r <br /> ( 925 ) 551-7555 !& -7 U <br /> PHONE ICI Err. BOS DISTRICT FLOCAT;ON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> LIDDY MCKENZIE CHECK If BILLING ADDRESS[ <br /> BUSINESS NAME Ca@flier Ryan Inc. PHONE# EXT. <br /> Y 925 551-7555 <br /> HOME or MAILING ADDRESS 6747 Sierra Court, Suite J FAx# <br /> ( 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 Hr.ALTH DEPARTMF.NT 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 th t ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED aws. <br /> APPLICANT'S SIGNATURE: DATE: 12- ZC�W <br /> PROPERTY/BUSINESS OWNER❑ OPERATO !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 HEALTii 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: L.l 'S'7 �'=-d <br /> COMMENTS: �v ✓ <br /> REPLACE 89 TURBINE SENSOR (PART NO. 794380-323). bc� <br /> OV <br /> SP CNV\FLO�pPR-tME <br /> ACCEPTED BY: lv' t�'�-/} EMPLOYEE#: C)3'2- I DATE: Z f <br /> ASSIGNED TO: g�j(y— EMPLOYEE#: 'C-1 1 S S' DATE:12 Z OD•- <br /> Date Service Completed (if already completed): SERVICE CODE:I PIE: <br /> 3_ <br /> Fee Amount: 2 S•Lry Amount Paid S d 0 Payment Date Z I <br /> Payment Type V S Invoice# Ghe� `p 3 5 Received By: <br /> EHD 48-02-025 Cox SR FORM(Golden Rod) <br /> REVISED 1 1/1 712 003 <br />