Laserfiche WebLink
19255517888 Main Fax GETTLER RYAN INC 19 P.M. 04-16-2007 3/10 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION <br /> OWNER/OPERATOR <br /> CHEVRON CHECK if BILLING ADDRESS <br /> FACILiTvNAME CHEVRON 209167 <br /> SITEADDRESS 1234 E YOSEMITE AVE MANTECA 95336 <br /> Street Number I Dir i n Street Name city Zia 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 E"T• 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 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME or MAILING ADDRESS FAx# <br /> 6747 Sierra Court, Suite J <br /> ( 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 tha the wor ,o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR!tifANAx0off'of <br /> ❑ OTHER AUTHORIZED AGENT Agent for Owner <br /> If APPLICANT is not the BILLINGPARTY,p 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 ENV]RONMENTA JiEALTH 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 RE4UESTED; REPLACE DRAWN VALVE AND O-RING <br /> COMMENTS: <br /> REPLACE DRAIN VALVE AND/O:-RING C61 l✓IUU)ALL <br /> P 44-- (.011�rl)lp `al "5q q2o CouNv <br /> sA E O OtA MEN? <br /> EpA <br /> ACCEPTED BY: EMPLOYEE#: DATE: IY—l —O <br /> lub JL <br /> ASSIGNED TO: ` EMPLOYEE#: 'z --:T O DATE: 1� <br /> Date Service Completed (if already completed): SERVICE CODE: i q R PIE: '130 <br /> Fee Amount: f 2 y-OD Amount Paid 5 , Payment Date y k b D7 <br /> Payment Type Vie- Invoice# C Cck# Sy/�7,0 <br /> Received By: <br /> EHD 48-02-025 (9k SR FORM(Golden Rod) <br /> REVISED 11717/2003 <br />