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^� e <br /> SAN JOAPIN COUNTY ENVIRONMENTAL HEALTH DEPARTME <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 5A-C(t7 9 D% 1 '5�— MWI,,P�) I <br /> OWNER/OPERATOR <br /> CHEVRON PRODUCTS COMPANY CHECK If BILLING ADDRESS <br /> FACILITY NAME CHEVRON SS#208117 <br /> SITE ADDRESS 755 S TRACY BLVD. TRACY 95376 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT,SUITE G <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> DUBLIN CA 94568 <br /> PHONE#1 EXT. APN# Zq2a0 LAND USE APPLICATION# <br /> ( 925 ) 551.7555 —432 9460 440-0006 <br /> PHONE#2 EXT. BOS DISTRICT LOCA^TTIO�N.,CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE CHECK If BILLINGADDRESS� <br /> BUSINESS NAME Gettler Ryan Inc. PHONE 551.7555 EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 6805 SIERRA COURT,SUITE G ( 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ��49-�� DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E;r Agen for Owner <br /> If APPL/CANT 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 PA the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ �l�f7' <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the#s! efvrp?U <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: DISPENSER/UDC UPGRADE AND TANK CONVERSION 20 <br /> COMMENTS: ENVIROHMCo <br /> L) Ty <br /> REMOVE/REPLACE WITH 6 NEW GILBARCO ENCORE 3+0 DISPENSERS WITH NEW HANGING TAL <br /> REPLACE EXISTING UDC PENETRATION FITTINGS WITH NEW BRAVO UDC PENETRATION FITTINGS. ME T <br /> RELOCATE PLLD'S TO TOP OF TURBINES. REPLACE TANK SUMP SENSORS WITH NEW VR 209 SENSORS. <br /> REPLACE PHIL-TITE SPILL BUCKETS WITH OPW SPILL BUCKETS (VR-101 TO VR-102) <br /> ACCEPTED BY: 11M <br /> EMPLOYEE#: DATE: J <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I 14 11 PIE: 2 O <br /> Fee Amount: "lC15 V", Amount PailP s,D� Payment DI ate 7 <br /> 1(9 <br /> Payment Type Invoice# Check# 12Z Z Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />