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9255517899 Line122 p.m. 10-20-2010 2/8 <br /> wi['A1l V Vraa \..V V1[1 1 111\Y AA\VL\1tiL`1\1 t%'11.G & i'1ft1111YA1a'1�A <br /> SERVICE REQUEST <br /> Type of Business or Property ,_ FACILITY ID# SERVICE REQUEST# <br /> GASOLINE STATION <br /> OWNER i OPERATOR <br /> MICHELLE CASTLE CHECK if BILLING ADDRESSO <br /> FAciuTYNAME CIRCLE K (2705446) <br /> SITE ADDRESS 1403 COUNTRY CLUB BLVD STOCKTON 95204 <br /> Street Number Direction Street a ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Namo <br /> CITY STATE ZIP <br /> (HONE#'1 ExT• APN* �� LAND USE APPLICATION# <br /> PHONE i2 Exr. BOS DISTRI= LOC DE <br /> ( 1 <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK IfAiLuge ADDRESS <br /> BUSINESS NAME PHONE# EAT. <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 SIERRA COURT (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 th he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED LI <br /> APPLICANT'S SIGNATURE: DATE: 10/20/2010 <br /> PROPERTY IBUSINESS OWNER❑ OP R/MANAGER ❑ OTHER AUTHORIZED AGENTI PROTECT MANAGER <br /> IfAPPLICANT is not the B INGPA.R 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST RETROFITML <br /> PAY U <br /> COMMENTS: <br /> PERMIT TO BREAK GROUND AND REPAIR LEAK UNDER DISPENSER ®CT 2 0 2010 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> j HEALTH DEPARTMENT <br /> ACCEPTEY: EMPLOYEE#: !� / DATE:zO <br /> ASSIGNED ,/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> L <br /> Payment Type m'C0." Invoice# # Received By: <br /> EHD 48-02-025 -x ©okrz � �r •� O 6 SR FORM(Golden Rod) <br /> REVISED 11/97/2003 <br />