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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> SERVICE STATION 0��� � � s R00 $ T o 4 <br /> OWNER i OPERATOR <br /> CHEVRON PRODUCTS COMPANY CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME CHEVRON SS# 210997 <br /> SITE ADDRESS 1442 COLONY ROAD RIPON 95366 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) SIERRA COURT, SUITE G <br /> 6805 Street Number Street Name <br /> CITY STATE ZIP <br /> DUBLIN , CA. CA 94568 <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( 925 ) 570 . 5575 26112028 <br /> PHONE #2 EXT, R E VED <br /> LOCATION CODE <br /> ( ) ::1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE OU 1 5 2019 CHECK If BILLING ADDRESS 121 <br /> ENVIRONMEN A�OMq � A EXT, <br /> BUSINESS NAME GETTLER RYAN INC . 15��5575 <br /> PE <br /> HOME or MAILING ADDRESS FAx # <br /> 6805 SIERRA COURT, SUITE G ( 925 ) 551 . 7888 <br /> CITY DUBLIN , CA . 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 : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / NIANAGER ❑ OTHER AUTHORIZED AGENT r Ag nt for Owner <br /> IfAPPLICANT 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 theBBroperty located at the <br /> above site address , hereby authorize the release of any and all results , geotechnical data and/or envirolii� ite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available me it is <br /> provided to me or my representative . <br /> TYPE OF SERVICE REQUESTED : FUELING SYSTEM UPGRADERA <br /> J-W VV , <br /> COMMENTS : � � Q(/IH <br /> REPLACE DISPENSERS WITH NEW GILBARCO 3 + 0 DISPENSERS/ HANGING HARDV� �y <br /> REPLACE ( E ) UDC ' S WITH DOUBLE WALLED UDC ' S/ PENETRATION FITTINGS AND NEW 4�C30T <br /> 208 SENSORS , REMOVE AND REPLACE TANK TURBINES WITH NEW RED JACKET TURBINES <br /> PLLD ' S , FLEX CONNECTORS AND BALL VALVES , REPLACE TANK SUMP SENSORS W/209 SENSORS 0 <br /> ACCEPTED BY : EMPLOYEE # : DATE: <br /> ASSIGNED TO : G O EMPLOYEE M DATE: F jO J <br /> Date Service Completed ( if already corp eted) SERVICE CODE : / P / E � <br /> Fee Amount : 400 Amount Paid Payment Date J / � <br /> Payment Type Invoice # Check # D Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />