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*CEIVED <br /> MAY 3 12018 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEVARTMENT <br /> ENVSERVICE' REQUEST �, se �VP�;o�i i L <br /> l <br /> Type of Business or Property FACILITY ID# SERVICE REQ <br /> HOSPITAL <br /> OWNER/OPERATOR CHECK if EtiLLING ADDRESS <br /> KAISER PERMANENTS <br /> FACILITY NAME KAISER STOCKTON <br /> SITEADDRESS 7373 LANE STOCKTON 95210 <br /> Street Number Imet Name Citv ZiDCods <br /> Holm or MAILIN©ADDRESS (it 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 O LAND USE APPLICATION# <br /> ( 925 ) 551.7555 ®q q ,l <br /> V <br /> PHONE#2 Em BOS D1STRILACATION CODE <br /> I ) — a/-0%" <br /> 1 01 <br /> CONTRACTOR/SERVICE VEST <br /> REQUESTOR LIDDY MCKENZIE CHECK If BILLING ADDRESS <br /> BUSINESS NAME: Gettler Ryan Inc. PHONE# 551.7555 ExT <br /> 925 <br /> H®ME Or MAILING ADDRESS FAX# <br /> 6805 SIERRA COURT,SUITE G ( 925) 551-7888 <br /> CITY DUBLIN STATE CA ZIP 94568 R C!® L+ <br /> OU <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of rqL <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project E3�j <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: S�Gg jtj F� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA14AGER 13 OTHER AuTKo1uzED AGENT Agent for Owner <br /> If APPLICANT is not the BILLING PAR TY proofofaittliorizatioit to sigh Is required Title <br /> AUTHORIZATION TO RELEASE INFO ATION: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: REPLACE ONE L2 ANNUAL SPACE SENSOR l 5T <br /> COMMENTS: <br /> REPLACE ONE VEEDOR ROOT 407 ANNUAL SPACE SENSOR WITH A NEW VEEDOR ROOT 409 ANNUAL <br /> SPACE SENSOR <br /> ACCEPTED Y: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: t� P 1 E: g <br /> Fee Amount: Amount Pa 4S Payment Date j (� <br /> Payment Type Invoice# Check# Recei ed y: <br /> EHD 48-02-025 SR FORM(Gown Rod) <br /> REVISED 11/17I2003 <br />