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SAN JOAQUI, -OUNTY ENVIRONMENTAL HEALTH. _.:PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Service Station F"00 3 3 o S P-00 40 75-2-- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Arco <br /> FACILITY NAME Mercedes Acosta Arco Station # 0595 <br /> SITE ADDRESS North High a99 Stockton 95212 <br /> 6100 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court, Suite J <br /> Street Number Street Name <br /> CITY Dublin STATE CA <br /> ZIP 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Scott Polston CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Gettler Ryan Inc. ( 925 ) 551-7555 <br /> HOME Or MAILING ADDRESS 6747 Sierra Court Suite J FAX# <br /> ( 925 ) 551-7888 <br /> CITY Dublin STATE CA ZIP 94568 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 applic on and th the k to b f will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S E F R la s. J <br /> APPLICANT'S SIGNATURE: r AT <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTE] Permit Expeditor <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 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: LAST EIVED <br /> COMMENTS: <br /> NOV 9 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L_(Up t /J A EMPLOYEE M b 3 Z� DATE: 1 C <br /> ASSIGNED TO: I EMPLOYEE M 3,_S',rt� DATE: lir <br /> Date Service Completed (if already completed): SERVICE CODE: <98 P/E: <br /> Fee Amount: l y��,��. Amount Paid q 9,6() Payment Date I11105 <br /> Payment Type Invoice# Check# 'as 9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />