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192555178E8 Main Fax GETTLER RYAN INC '7:56 p.m. 05-03-2007 3111 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> n :- <br /> SERVICE STATION _� �� �. x� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO 6020 <br /> SITEADDRESS 1711 E YOSEMITE AVE MANTECA 95336 <br /> Street Number Direction Street Name CI 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 COD <br /> ( ) C— T^ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 Sierra CourtSuite J <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 application and t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an#E aws. f`� <br /> APPLICANT'S SIGNATURE: DATE: v <br /> PROPERTY/BUSINESS OWN ER OPERATOlffmANAGER ❑ OTHER AUTHORIZED AGENT W Agent for Owner <br /> If APPL/CANT is not the BILLING PARTY,proof of authorization to sign is required TW e <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: UST RETROFIT 'ECEIVEE <br /> COMMENTS: <br /> REPLACE DISPENSER PAN SENSOR (794380-323)ON DISPENSER#3/4 MAY 3 2�� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ,( HEALTH DEPARTMENT <br /> ACCEPTED BY: 4,4- ,,:614 U Lrt�. �� EMPLOYEE#: b�L?ta, C,32 i DATE: S 3 V 7 <br /> ASSIGNED TO: k�,A—[ O-Lc EMPLOYEE#: )..(� J t✓ DATE: 5 <br /> Date Service Completed (if already completed): SERVICE CODE: / P 1 E. L ,r <br /> Fee Amount: 4- Z Amount Paid �8 S D� Payment Date ,3/o <br /> Payment Type r r, I Invoice# Check# Received By: <br /> EHD 48-02-025 R^^ VC A G aD `-0 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />