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9255517899 Line 1 006 p.m. 09-08-2010 2/9 <br /> VHI� VVH�V�VIII\11 ibl\Y11\Vl\lYlEl\1HL L1GH41I] Hllllq Gl\1 <br /> SERVICE REQUEST <br /> Type of Business or Property /FACILITY ID# SERVICE REQUEST#/_ <br /> GASOLINE STATION <br /> OWNER/OPERATOR <br /> Alex Steele CHECK if BILLING ADDRESS❑ <br /> FACIunNAME PG&E#6027038 <br /> SITEADDRESS 4040 West Lane Stockton <br /> tree[Number <br /> Dimcffi.n Sreet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 SIERRA CT. <br /> Street Number Street Name <br /> Crry DUBLIN STATE CA ZIP 94568 <br /> PHONE#1 Ezr. APN# LAND USE APPLICATION# <br /> (209) 337-8902 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECKif BILLINGAOORESS� <br /> BUSINESS NAME PHONE# EAT• <br /> Gettler Ryan Inc. 209 337-8902 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 SIERRA CT. (209) 551-7888 <br /> CITY DUBLIN STATE CA ZIP 94568 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent or 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/}1et the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE 900f' <br /> •l7ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; n <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ff APPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT CEIVED <br /> COMMENTS: ZOln <br /> Replacement of Waste Oil CT Flex Boot SEP U <br /> 6 <br /> SAN JOAOUl1`I COUNTY <br /> ENVIRONMENTAL <br /> HFALTH DEPARTMENT <br /> ACCEPTED BY: O(_l lJ�I 0-4 EMPLOYEE D DATE: C?Ielt a <br /> ASSIGNED To: L��� EMPLOYEE#: DATE: CZ'- d7' (•� <br /> Date Service Completed (if already completed): SERVICECODE: P I E: <br /> Fee Amount: 4 3(4,, ,-p Amount Paid Payment Date Q 166 <br /> ape CI, Invoice# Va.S -er Ca-r. Received By: <br /> EHD 48-02-025 C" * P <br /> REVISED 11117/2003 <br /> J SR FORM(Golden Rod) <br /> 3bb • o� <br />