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19255517888 Main Fax GETTLER RYAN INC 4:05 a.m. 09-25-2007 3/11 <br /> SAN JOAQUINIPOUNTY ENVIRONMENTAL HEALTH DEPARTMENT l04 f F f r Lj <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> Equilon Enterprises LLC/Shell Oil Products <br /> FACILITY NAME TOKAY SHELL <br /> SITE ADDRESS 420 W KETTLEMAN LN LODI 95240 <br /> Street Number Direction Street Nam city ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court,Suite J <br /> Street Number ea N e <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECKif BILLING ADDRESS <br /> PHONE# EXT' <br /> BUSINESS NAME Gettler Ryan Inc. 928 551.7555 <br /> HOME Or MAILING ADDRESS FAx# <br /> 6747 6747 Sierra Court,Suite J ( 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 rk to b fo. will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL I S. �j <br /> APPLICANT'S SIGNATURE: DATEE��:( Z © t <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MSI GER ❑ OTHER AUTHORIZED AGENT 9a 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is availabled at the same time it is <br /> provided to me or my representative. AYME <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT [� J[VED <br /> COMMENTS: r 2 top <br /> REPLACE RED JACKET DIESEL LEAK DETECTOR (P/N 116-058-5) SAN JOAQUIN COUNTY <br /> HEALTH DEPA NTgL TY <br /> NTAL T <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Com eted (H already completed): SERVICE CODE: / PIE: U <br /> Fee Amount: Z Amount Paid q `^ r�� Paym nt Date 7 <br /> Payment Type aS�t Invoice# C3P.ck.?F ` Received By: Cr" <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />