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SAN JOAQUI1. —OUNTY ENVIRONMENTAL HEALTH _—PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Service Station VA-00 3 -s'"o gg7S.S <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Serpa's Ampm Mini-Market <br /> FACILITY NAME Arco Service Station # 06080 <br /> SITE ADDRESS East Louise Avenue Lathrop 95330 <br /> 85 Street Number I Direction Street Name citv Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court, Suite J <br /> Street Number Street Name <br /> CITY <br /> YDublin STATE DA Zip 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Scott Polston CHECK If BILLING ADDRESS <br /> BusiNEss NAME Gettler Ryan Inc. ( 925 EXT. <br /> 551-7555 <br /> HOME Or MAILING ADDRESS 6747 Sierra CourtSuite J Fax# <br /> ( s2s ) 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 applic ion and th he wo <to be perfarmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S Ea F AL w ---- / <br /> APPLICANT'S SIGNATURE:PROPERTY/BUSINESS OWNER❑ OPERATOR/V ANAGER ❑ OTHER AUTHORIZED AGENT p Permit Expeditor <br /> If APPLICANT is not the BILLING PARTY,proof'of authorization to sign is required Title <br /> AUTHORIZATION TO 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/S' a assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabblle,�lt�\ �vre time it is <br /> provided to me or my representative. /� �(( <br /> TYPE OF SERVICE REQUESTED: U._S j !�-marts 'Of- t T TO <br /> COMMENTS: O GO 00 <br /> N N�ONgo\NA EN,MENT <br /> SP EN�\V O�pPP <br /> N <br /> ACCEPTED BY: U�y t vl�_14 EMPLOYEE#: Z� DATE: cl r O S <br /> ASSIGNED TO: A G_ EMPLOYEE#: �''j -G DATE: <br /> Date Service Completed (if already completed): SERVICE CODE/: q P 1 E: 2_3 <br /> Fee Amount: 7 _ ;} Amount Paid7 g v O Payment Date S <br /> Payment Type Invoice# Check# eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />