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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Corporation Yard [ ' r' ya q/ i <br /> OWNER / OPERATOR <br /> RAMOS OIL COMPANY CHECK If SEES <br /> BILLING ADDRESS ❑ <br /> NIS <br /> FACILITY NAME RAMOS OIL COMPANY <br /> SITE ADDRESS 10842 S HARLAN ROAD FRENCH CAMP 95231 <br /> Street Number Directlon Street Name Cit 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 # LAND USE APPLICATION # <br /> ( ) 178 -14 -019 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Liddy McKenzie ( CONTRACTOR) CHECK if BILLING ADDRESS <br /> BUSINESS NAME GETTLER-RYAN , INC PHONE # EXT, <br /> HOME Or MAILING ADDRESS FAX # <br /> 6805 SIERRU ( ) 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 FFEDERAL laws . <br /> APPLICANT ' S SIGNATURES Z DATE : 2/03/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 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 at the same time it is <br /> provided to me or my representative . ft <br /> TYPE OF SERVICE REQUESTED : INSTALL NEW PLLD IN EXISTING TURBINE �C� <br /> COMMENTS : <br /> SqN U <br /> EN �QUt <br /> EXISTING MLLD WITH A NEW VEEDOR ROOT PLLD AND COLD START . NSC N �EpgR�t. <br /> FNP <br /> ACCEPTED BY : f -� Lt EMPLOYEE # : DATE : <br /> ASSIGNED TO : /) `� J EMPLOYEE # : DATE : 2 <br /> Date Service Completed ( if already completed) : SERVICE CODE : PIE : <br /> Fee Amount : Amount Paid � ( � Payment Date /� Lr ;. .. � <br /> Payment Type Invo' e # Check # ReTReceived By : <br /> EHD 48-02-025 � l �SJ � �( � SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 vim/ Tt <br />