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+ SAN JOAQUINOOUNTY ENVIRONMENTAL HEALTH&ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Service Station r__A*o 19'77 r600 gOS-4 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS 11 <br /> Arco <br /> FACILITY NAME Bp O i I <br /> SITE ADDRESS west Hammer Lane Stockton 95209 <br /> 3250 Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court, Suite J <br /> Street Number Street Name <br /> CITY Dublin STATE CA 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 PHONE# EXT. <br /> Gettler Ryan Inc. ( 925 551-7555 <br /> HOME Or MAILING ADDRESS 6747 Sierra Court, Suite J �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 applic on and at ork to rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S'Ixlm <br /> APPLICANT'S SIGNATURE -' <br /> DATE. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT O Perml Expeditor <br /> If APPLICANT 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: L�S 1' 4P--Imo-6F l-T <br /> COMMENTS: Mil [44 &A1Mfg"A <br /> ACCEPTED BY: C)L,t U f l e A- EMPLOYEE M 032-1 DATE: j) f�b�— <br /> ASSIGNED TO: 1.._1E_ EMPLOYEEM SS DATE: l <br /> Date Service Completed (if already Completed): SERVICE CODE g<� P/E: <br /> Fee AmountA ;4 7'�,C,C> Amount Paid a^? Payment Date ( L <br /> Payment Type Invoice# Check# ' L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />