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` SAN JOAQUI*UNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Service Station FA-000 3 &C "0 q'4 793 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Arco <br /> FACILITY"AME Fremont Arco <br /> SITE ADDRESS WestFremont Street Stockton 95203 <br /> 1617 Street Number Direction Street Name city Zip 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 ExT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Scott Polston CHECK If BILLING ADDRESS R1 <br /> BUSINESS NAME PHONE# ExT <br /> Gettler Ryan Inc. ( 925 ) 551-7555 <br /> HOME Or MAILINGADDRESS 6747 Sierra Court ( 9 Suite J <br /> ( s25 ) 551-7888 <br /> CITY Dublin STATE CA ZIP 94568 <br /> BILLING ACKNOWLEDGEMENT: 1, 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. I <br /> I also certify that I have prepared thisapplica ' n and tha a rk to e per a Ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST E a E AL w . <br /> APPLICANT'S SIGNATURE - ��__ti� DATE; 1-,'2-,Z � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El Permit Expeditor <br /> ifAPPLICANT 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: L'� S T �'->✓7 -C'�C--t T <br /> COMMENTS: <br /> ACCEPTED BY: G L �i�l EMPLOYEE#: .2DATE: C� <br /> ASSIGNED TO: Z L7 U, EMPLOYEE#: �1 7 e DATE: q ( G.� <br /> Date Service Completed (if already completed): SERVICE CODE: l rt P i E: 0 <br /> Fee Amount: Z c Amount Paid q O0 Payment Date N bS <br /> Payment Type ✓ Invoice# Check# S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />