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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10 N SERVICE REQUEST# <br /> SERVICE STATION TrA We? -5 00—K7491-J <br /> OWNER I OPERATOR tf�❑ <br /> JASS ENTERPRISES <br /> FAcam NAPE WOODBRIDGE AMPM <br /> StTEADDREss 48B06 LOWER SACRAMENTO ROAD WOODBRIDGE 95258 <br /> -tr SbV*tN41"W CRY _Z <br /> twedhm <br /> HDPE Or MAILING ADmas (H Different from Site Addrmal <br /> [tom Ec�� Nr <br /> CITY STATE LP D <br /> DUBLIN CA 945M <br /> PHONE t1 APN k uwo USE APPLN:ATM* DCC 0 <br /> ( 925 t 551.7555 C 2 02Q <br /> PHONE#2 Fir. BOfi DISTRICT RON1tV <br /> M 11N7Y <br /> CONTRACTOR/SERVICE REQUESTOR ARTME)yr <br /> REgUESTOR Liddy McKenzie(CONTRACTOR) CHECK it BILLING Add RESS121 <br /> EirT- <br /> BUSINESS NAME GETTLERAYAN,INC PROg� 551-7555 <br /> HomE or MAILING ADDRESS FAx# <br /> 6805 SIERRA COURT,SUITE G ( 925) 551.7888 <br /> CnY DUBLIN STATE 71P <br /> CA 94MB <br /> BILLING ACKNONVLEDGEMENT' I, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HGALTIi DEPARTMENT(sourly charges associated with this project <br /> or activity will he billed to rue or my husincss as identified on this form <br /> I also certify that I have prepared this application and dsal a work to •performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Orilinance Codev,Standards•STATE and I'E [,la <br /> APPLICANT'S SIGNATURE: D,�TE: 1/h?A 0 Z_� <br /> PROPERTY l BL'SINESS OWNER❑ PE(UTnH I M11A4AGEn 13 OTHER AtrTHORIZED AGEM1T❑ Agent for Owner <br /> 1f,'fPPL1C tNT is nal dre flIl-LING P_4R7) Prnofaf aurhariW1inn/to sign is required Thin <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at[lie 5 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaVsite as.sesstncnt <br /> information 10 the SAN JOAQUIN COUNTY LNVIRONNirNTAL HEALTH QGPARTNiLNT as soon as it is available and at the same time it is <br /> provided to me or my represenlative. <br /> TYPE OF SERVICE REQUESTED: l/ / <br /> COMMMS: <br /> REPLACE(4)OVATION DRESSER WAYNE DISPENSERS WITH(4)NEW OVATION-2 DISPENSERS AND VST <br /> HANGING HARDWARE. <br /> CONVERT HEAL.Y ASSIST SYSTEM VR-202 TO BALANCE SYSTEM VR-204 0 <br /> ACCEPTED BY: C' `/ !' EMPL.GYIIE 0: DATE: D�� <br /> AfSt6t1®TD: EmpLoyo0: DATE: �>1 <br /> Oats Service Completed (if already corllplated): — &ERVICECooI; Q P 1 E <br /> Foe Amisun + 0t7 Amount Pal L�SG Uo Payment Date 1 �� <br /> Payment Type Invoice* Ctlack# $ Rel elv By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />