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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST of Business or Property FACILITYIDE MERLIN BOWEN R 6T�i SERVICE KM HOSPITALb BUSINESS NAME Gettler Ryan Inc. ,# PHONE # SMS -� OWNER/ OPERATOR 925 KAISER MEDICAL GROUP HOME or MAILING ADDRESS CHECK If BILLING ADDRESS ❑ FACILITY NAME KAISER HOSPITAL MANTECA 6805 Sierra Court, Suite G SITE ADDRESS ( 925 ) 551-7888 CITY STATE ZIP Dublin 1777 W YOSEMITE MANTECA 95336 Street Number Direction Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) 6805 FSierra Court, Suite G Street Number Street Name CITY STATE ZIP Dublin CA 94568 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 925 ) 551-7555 rzt ) Ol" PHONE #2 EXT• ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR � MERLIN BOWEN CHECK if BILLING ADDRESS BUSINESS NAME Gettler Ryan Inc. PHONE # Exr. 925 551-7555 HOME or MAILING ADDRESS FAx # 6805 Sierra Court, Suite G ( 925 ) 551-7888 CITY STATE ZIP Dublin CA 94568 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE andFEDERALlaws. APPLICANT'S SIGNATURE: /` /5— DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER El OTHER AUTHORIZED AGENT � Agent for Owner If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site .ass f► FNT information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sable tim 1t�iD provided to me or my representative. JU TYPE OF SERVICE REQUESTED: LIST REPAIR COMMENTS: � N"OAni 20 rH PERFORM A COLD START ON AN EXITING TANK MONITORING SYSTEM THAT THE DISPLAY KEPT GOING OUT. ACCEPTED BY: EMPLOYEE #: DATE: - _ / ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E:`r� Fee Amount:C0� Amount Pai 3 Q� �/ Payment Date Ile Zs f S Payment Type Invoice # Check # �rf�3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003