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Mar -20-07 10:40am From-GettlerInc +925 551 7AARTMENT <br />T-333 P.002/010 F-136 <br />SAN JOAQU0ouNTYENVIRONMENTALMAL'1c <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR LIDDY MCKENZIE CHECK it BILLINGADDRes€0 <br />BUSINESS NAME PHONE # EXT. <br />Gettler Ryan Inc. 925 551 7555 <br />HOME or MAWNG ADDRESS FAX# <br />6747 Sierra Court, Suite J ( 925 1 551-7888 <br />crry Dublin STATE CA ZIP 94568 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or autborized agent of same, <br />acknowledge that 811 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 JOAQUnv <br />COUNTY Ordinance Codes, Standards, STATE F : WS. <br />APPLICANT'S SIGNATURE: DATES:(_ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MA A 'R ❑ OTHER AUTHORIZED AGENT W1 Agent for Owner <br />IfApPL/CANT is not the Ell LING PARV proof of authorization to sign is required Tirre <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 HzALTH DEPARTMENT as soon as it is available and lie same time it is <br />provided to me or my representative_ YM <br />TYPE OF SERVICE REQUESTED: UST RETROFITC4 <br />COMMENTS: <br />re— <br />MAR <br />Upgrading to a single port manway with one bucket on a diesel tank. <br />OU1N OpUNN <br />SAN JOA ONMENTAL <br />ENV1R <br />N�,tTH DE PARTMEtsf <br />ACCEPTED BY' vu� (Va.— <br />R, <br />EMPLOYEE #' <br />3 / <br />DATE. 2 <br />ASSIGNED TO: 2 `�,� <br />EMPLOYEE #: <br />15 <br />�121/153 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P'E: o <br />Fee Amount: - Gb 1Amount Paid <br />28 S -t V 0 <br />Payment Date 41,740-7 <br />Payment Type AL— invoice # <br />Check # <br />received By: 1-2,� <br />EHD 48-02-025 "J A A y y 7D` j SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />