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SAN JOAQUI&UNTY ENVIRONMENTAL HEALTH OPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> ARCO <br /> FACILITY NAME ARCO <br /> SITE ADDRESS TRACY BLVD TRACY 95376 <br /> 3425 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 21418020 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Scott Polston CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> Gettler Ryan Inc. ( 925 551-7555 <br /> HOME Or MAILING ADDRESS 6747 Sierra Court Suite J Fax# <br /> � ( 925 ) 551-7888 <br /> c" 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El Permit xpeditor <br /> IfAPPLICANT 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: <br /> COMMENTS: <br /> Q,FQ � LtJI!b L <br /> ACCEPTED BY: EMPLOYEE M DATE: 41 <br /> ASSIGNED TO: EMPLOYEE M 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: , <br /> Fee Amount: Amount Paid 011 Payment Date �1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golde Rod) <br /> REVISED 11/17/2003 <br />