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19255517888 Main Fax GETTLER RYAN INC 10:08:58 a.m. 12-06-2006 <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 />COMMENTS: <br />( 925) <br />C<, c 0 4 O L-, 9 <br />OWNER i OPERATOR <br />CHECK it BILLING ADDRESS <br />Nella Oil Company <br />551-7888 <br />FACILITY NAME Olympian "Flyers" <br />STATE CA <br />SITE ADDRESS <br />I <br />Moffat Blvd <br />DATE: / <br />Manteca <br />EMPLOYEE M / O <br />983 Street Number <br />Direction <br />Street Name <br />P 1 E: <br />City <br />Zip Code <br />Payment Date <br />Payment Type <br />HOME or MAILING ADDRESS (If Different from Site Address) 6747 <br />Sierra Court, Suite J <br />Street Number <br />Street Name <br />CITY Dublin <br />STATE C LP 94568 <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />( 925 ) 551-7555 <br />PHONIER ExY. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Liddy McKenzie <br />ENT <br />CHECK if BILLING ADDRESS <br />Bus+NEss NAME Gettler Ryan Inc. <br />COMMENTS: <br />( 925) <br />551.7555 <br />HOME D►MAILING ADDRESS 6747 <br />Sierra Court Suite J <br />Fax# <br />( 925 ) <br />551-7888 <br />OTY Dublin <br />STATE CA <br />ZIP 94568 <br />3/10 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 the the rk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FED1 L <br />APPLICANT'S SIGNATURE: DATE:. <br />►�(Z���� <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT M 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />Drovided to me or mY representative. / <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />ENT <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />DEC 0 6 2006 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: / <br />ASSIGNED TO: <br />EMPLOYEE M / O <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid Y'oZgcJ <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: N� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />