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SAN JOAQUi— 4—'OUNTY ENVIRONMENTAL HEALTh "EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> West Valley Chevron <br /> FACILITY NAME 8363464 <br /> SITE ADDRESS 2615 West Grantline Road Tracy 95304 <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 Sierra Court,Suite G <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 408 ) 636-6651 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAMEy PHONE# EXT. <br /> Gettler Ryan Inc. 408 636-6651 <br /> HOME or MAILING ADDRESS FAX# <br /> 6805 Sierra Court,Suite G ( 408 ) 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 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/MANAGER ❑ OTHER AUTHORIZED AGENT E;r Agent for Owner <br /> /f 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 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: SB989 Repair/Retest <br /> COMMENTS: <br /> REPLACE ELECTRICAL CONDUIT PENETRATIONS IN VENT RACK SUMP BOX AND NO. 7/8 DISPENSER <br /> UNDERCONTAINMENT BOX. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />