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19'255517888 Main Fax � GETTLER RYAN INC 10017 a.m. 03-12-2007 2/13 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID## SERVICE REQUEST# <br /> SERVICE STATION r L 7� �j q �i ry'1/ T <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS13 <br /> CHEVRON <br /> FACILITY NAME CHEVRON 9-6171 <br /> SITEADDRESS 6633 1 PACIFIC AVE STOCKTON 95207 <br /> Street Number LDIrection Street N m cityZipCode <br /> HOME or MAILING ADDRESS (if Different from Site Address) 6747 Sierra Court, Suite J <br /> Street Number Street Nam <br /> CITY Dublin STATE CA ZIP 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> { 925) 551-7555 <br /> PHONE 92 Err. SOS DISTRICT LOCATION CODE <br /> { 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# &T' <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME Or MAILING ADDRESS6747 Sierra CourtSuite J FA 2 <br /> { 9 925 ) 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 th t the <br /> ork t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED, /L ' / <br /> APPLICANT'S SIGNATURE: 1,t! DATE: { 2 7 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER <br /> OTHER AUTHORIZED AGENT91 <br /> Agent for Owner <br /> IfAPPLICANTis not theBLLLixGPARTY,proofofauthorization to sign is required Title <br /> AUTHOR17.ATION 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/stiitle,assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availal0A4%Ar= ame time it is <br /> provided to me or my representative. covE® <br /> TYPE OF SERVICE REQUESTED: �S` 12 a <)R T- <br /> COMMENTS: <br /> REPLACE PLLD MODULE(330374-001)FOR THE 87&89 TANKS. UIN COUNT'i <br /> SA JOAQUIN <br /> TMENT <br /> HEpt.TN DEPAR <br /> ACCEPTED BY: OA EMPLOYEE#: h 3 I DATE: 2 f 2 O <br /> ASSIGNED TO: Z c 116a r EMPLOYEE#: 8 3 1 DATE: 2 (200-7 <br /> Date Service Completed (if already Completed): SERVICES CODE: 2 $ PIE: Ci <br /> Fee Amount: 2 8 �� (�U Amount Paid - 2�S 0-0 Payment Date 3 /3 <br /> Payment Type :"C Invoice <br /> ��# Check# Received By: <br /> EHD 48-02-025 t3(—I K-" ` d'" �L170 /Q SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />