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19255517888 Main Fax 0 GETTLER RYAN INC 3:05 P.M. 01-11-2007 2111 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />SERVICE STATION%:� <br />f <br />! -� <br />Z�l <br />32 U G <br />OWNER I OPERATOR <br />Sierra Court, Suite J <br />ARCO <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ARCO <br />STATE CA <br />SITE ADDRESS <br />TRACY BLVD <br />TRACY <br />95376 <br />3423 SlraetNumber <br />Direction <br />Street Name <br />Ci <br />e <br />ROME or MAILING ADDRESS (If Different from Site Address) 6747 <br />Sierra Court, Suite J <br />Street Number <br />Street Name <br />CITYDublinSTATE <br />CA ZIP 94568 <br />PHONE 11 En. <br />APN # <br />LAND USE APPLICATION # <br />{ 925 ) 551-7555 <br />PHONE #2 ExT• <br />( ) <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />LIDDY MCKENZIE <br />CHFCK if BILLING ADDRESS <br />BUSINESS NAME Gettler Ryan Inc. <br />Y <br />PHONE# <br />925 <br />EXT. <br />551-7555 <br />HOME or MAILING ADDRESS 6747 <br />Sierra Court, Suite J <br />FAx# <br />( 925 ) <br />551-7888 <br />CITY Dublin <br />STATE CA <br />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 />I also certify that I have prepared this application and t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an IF laws. <br />APPLICANT'S SIGNATURE: DATE: % it <br />PROPERTY/BUSINESS OWNER❑ OPER R /M AGER ❑ OTHER AUTHORIZED AGENT Permit Expeditor <br />!f APPLICANT is not the BILLING PAR , 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/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a time it is <br />provided to me or my representative. P�(� <br />TYPE OF SERVICE REQUESTED: R <br />COMMENTS: <br />REPLACE 91 FILL SUMP SENSOR (PART NO. 794380-323).JPoA C.O Asiv <br />pV1N <br />SW 14 0 PARS�ENT <br />H <br />ACCEPTED BY: Iv "I EMPLOYEE M V 1'�3 #DATE: <br />l—O -7 <br />ASSIGNED TO: W IJA EMPLOYEE #: (� Ibate Service Completed (if already completed): SERVICE CODE: Oi: 'L3o$ <br />Fee Amount: 'L�� Amount Paid ' 'S Payment Date <br />l i(f -7 <br />Payment Type — Invoice # Check # . Received 8y: 4,( <br />EHD48-02-025 -l'A R 4-N q-7 SIR FORM (Golden Rod) <br />REVISED 11/1712003 <br />