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SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH IRARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> HOSPITAL nO J96 q-t) <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> KAISER PERMANENTE <br /> FACILITY NAME KAISER STOCKTON <br /> SITE ADDRESS 7373 We-* LANE STOCKTON 95210 <br /> Street NumbStreet Name city Zio Code <br /> HOME Or MAILING ADDRESS (If 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# LAND USE APPLICATION# <br /> ( 925 ) 551.7555 /q) V <br /> PHONE#2 EXT. BOS DISTRII�T LOCATION CODE <br /> ( ) ()V V <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK If BILLING ADDRESS <br /> YMF <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# Exr.925 551.7555 111I�� <br /> HOME Or MAILING ADDRESSS�� <br /> FAx# 'v�® <br /> 6805 SIERRA COURT,SUITE G ( 925 ) 551-7888 ''�V 9 <br /> CITY STATE ZIP �0�`� <br /> DUBLIN CA 94568 E9( RO C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of Sam4Vh�' <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projectFiy� <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: 5� GB� U <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I;r Agent for Owner <br /> If 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: REPLACE ONE L2 ANNUAL SPACE SENSOR <br /> COMMENTS: <br /> REPLACE ONE VEEDOR ROOT 407 ANNUAL SPACE SENSOR WITH A NEW VEEDOR ROOT 409 ANNUAL <br /> SPACE SENSOR AND PERFORM A COLD START. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: G{ J S(v <br /> Date Service Completed (if already completed): SERVICE CODE: ' Cd PIE: 2 O <br /> Fee Amount: CJ Amount Pa TSCA. Payment Date $ <br /> Payment Type Invoice# Check# / Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />