Laserfiche WebLink
9255517899 Line 1 • 0 :33 a.m. 10-11-2010 2/11 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GASOLINE STATION 7--7i I-) le <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ARCO #2093 <br /> SITEADDRESS 3425 TRACY BLVD TRACY 95330 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 6747 SIERRA CT. <br /> Street Number Street Name <br /> CIN DUBLIN STATE ZIP <br /> CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (925) 551-7555 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLINGADDRESSS] <br /> BUSINESS NAME PHONE# ExT• <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 SIERRA CT. (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 the work to ed.will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and I / <br /> APPLICANT'S SIGNATURE: DATE: L �f <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <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: UST RETROFITSE <br /> COMMENTS: <br /> REPLACEMENT OF 8 MASTER FILL SENSOR L6 P/N 794380.323 (LIKE F PqL } UNC <br /> SP1AN'Rko P Ole] <br /> ACCEPTED BY: o( t V�t EMPLOYEE#: 0-32-f DATE: p C( vo <br /> ASSIGNED TO: ��l EMPLOYEE#: ( f 2-1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: q9 P i E: � <br /> Fee Amount: 3( � c� Amount Paid Payment Date <br /> Payment Type Invoice# 6hat;Jcafk Received By: �{ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />