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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />SERVICE STATIONS <br />PHONE # <br />925 <br />btJ%311 <br />OWNER/ OPERATOR <br />CHECK If BILLING ADDRESS❑ <br />CHEVRON PRODUCTS COMPANY <br />FACILITY NAME CHEVRON SS#201383 <br />SITE ADDRESS 1960 <br />W <br />I <br />11TH STREET <br />I <br />STATE CA <br />TRACY <br />95376 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 6805 <br />Sierra Court, Suite G <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Dublin <br />CA 94568 <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />( 925 ) 551-7555 <br />PHONE #2 ExT• <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR LIDDY MCKENZIE <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME Gettler Ryan Inc. <br />PHONE # <br />925 <br />ExT. <br />551-7555 <br />HOME or MAILING ADDRESS <br />FAX # <br />6805 Sierra Court, Suite G <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 that the wor to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL la /,, <br />APPLICANT'S SIGNATURE: DATE: 1 <br />Ilsr— <br />PROPERTY / BUSINESS OWNER ❑ OPE TO AGER ❑ OTHER AUTHORIZED AGENT W Agent for Owner <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 f>I,� YMENI t is <br />provided to me or my representative. T G�� <br />REGEN <br />TYPE OF SERVICE REQUESTED: DISPENSER/UDC UPGRADE AND TANK CONVERSION SEP 14 <br />COMMENTS: <br />CONVERT EXISTING 91 UST TO DIESEL, CONVERT EXISTING 89 TO 91 UST. SAN JOAQUIN COU <br />ENVIiAOMENTAL <br />REMOVE EXISTING DISPENSERS AND UDC'S 001" DEPAR <br />ACCEPTED BY:EMPLOYEE M DATE:I . �_ / <br />ASSIGNED TO: J EMPLOYEE M DATE: `I"` _ <br />Date Service Completed (if already completed): SERVICE CODE: P I E: 23G`" <br />J <br />Fee Amount: Amount Paid 3 (>, D Payment Date / 7 <br />Payment Type C Invoice # Check # r / G Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />