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19255517888 Main Fax . GETTLER RYAN INC o 23 p.in. 01-26-2007 3/11 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST if <br /> SERVICE STATION y <br /> 3R 5?2�v L4 i 2, <br /> OWNER/OPERATOR <br /> ARCO CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO <br /> SITE ADDRESS 1, N WILSON STOCKTON 95205 <br /> 1250 veet Number I Direction I IRMt Name C. <br /> N I Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court, Suite J <br /> SI Number tree)Neme <br /> CITY Dublin STATE CA ZIP 94568 <br /> PHONE#1 Ev. APN# �7 LAND USE APPLICATION# <br /> ( 025 ) 551.7555 (I t — 310-01 <br /> PHONE#2 Exr. BOS DISTRICTI LOCATION CODE <br /> ( ) I (' t <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> LIDDY MCKENZIE CHECK MBILLING aDDREssm <br /> BUSINESS NAME Gettler 1 P <br /> Ryan Inc. %15 <br /> Y az557-7555 En, <br /> HOME Or MAILING ADDRESS 6747 Sierra Court, Suite J Fes`# <br /> ( 925 551.7888 <br /> CITY Dublin STATE CA LP 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 forrn. <br /> 1 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 FED AL �T <br /> APPLICANT'S SIGNATURE: DATE; 'Z0 O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ip Permit Expedhor <br /> 1f APPLICANT Is not rhe 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time kst-r <br /> provided to me or my representative. PAYM D <br /> TYPE OF SERVICE REQUESTED: L(_ST— O-E7t-40 F( T_ R <br /> COMMENTS: JAN 2 9 001 <br /> REPLACE 89-T�SENSOR (PART NO. 794380-323). <br /> JOAQUIN CO PL <br /> NEViH DEP 7M <br /> ACCEPTED BY: O L(V E EMPLOYEE#: 6.32-( DATE: 1 2 cL a7 <br /> ASSIGNEDTO: ttllt.AI C EMPLOYEE#: 4 ISS' DATE; f �� Q <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: 'S O-7D Amount Paid �e�g-S 0-� Payment Date Z-7 10 7 <br /> Payment Type Invoice# Check 9 Received By: <br /> ML ^_ .� /LRrv. <br /> EHD 48-02-025 W r Pr't9 0 6 I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />