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SAN JOAQUI1 OUNTY ENVIRONMENTAL HEALTH_ PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Service Station FP-L 3 12- 51200 q q7 49 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> Arco <br /> FACILITY NAME Yosemite Arco <br /> SITE ADDRESS East Yosemite Manteca 95336 <br /> 1711 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 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 <br /> 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: 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 appli tion and t the k to be ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S Ea ER <br /> APPLICANT'S SIGNATURE: ! -- DATE: g / _l <br /> PROPERTY/BUSINESS OWNER❑ OPERAT MANAGER ❑ OTHER AUTHORIZED AGENT O Permit Expeditor <br /> 1 f APPLICANT 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: -T F i T CEN <br /> COMMENTS: <br /> NOv 9 2p0 <br /> COIJg <br /> SPNVW4VEIRO1MEN <br /> NeNoH pE <br /> ACCEPTED BY: L;L_ EMPLOYEE#: DATE: <br /> ASSIGNED TO: fQ �� EMPLOYEE#: DATE: Q I4L l <br /> Date Service Completed (if already completed): SERVICE CGDE: /' PIE: 2.3 L,e <br /> Fee Amount: �� c tj Amount Paid :;1167 L�o Payment Date l S <br /> Payment Type ✓ Invoice# Check# a Received By: /'0,L , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />