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19255517888 Main Fax GETTLER RYAN INC 01:08:48 p.m. 10-23-2006 5/6 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Service Station CHECK if BILLING ADORESSE OWNER i OPERATOR CHECK if BILLING ADDRESS❑ ARCO BUSINEss NAME y Gettler Ryan Inc. FACIUTYNAME ARCO PHONE# 1325 SITE ADDRESS HOME or MAILING ADDRESS fi747 Joe Pombo Parkway FAX # ( 925 ) TRACY 95377 2 D Strwt NumMr Dk n t nw DATE: Ci ZI ode HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court, Suite J Stmot NumbersveetName SERVICE CODE: c"YDublin STATE CA zip 94568 PHONE#1 EXT• APN # Payment Type S P LAND USE APPLICATION # ( 925 ) 551-7555 21418020 PHONE ill F_ItT. ( ) BOS DISTRICT LOCATION CODE CnXTRACTM / SERVICE REOUESTOR r REQUESTOR CHECK if BILLING ADORESSE Scott POISton COMMENTS: fV 0 V J 3 BUSINEss NAME y Gettler Ryan Inc. Zoos PHONE# 1325 Exr 551-7555 HOME or MAILING ADDRESS fi747 Sierra Court, Suite J' FAX # ( 925 ) 551-7888 cITY Dublin STATE CA ZIP 94568 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application an that the ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and ERAL / APPLICANT'S SIGNATURE: Z DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR / MANA ❑ OTHER AUTHORIZED AGENT I] Permit Expeditor If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE I ORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is _.:a -A r.....e .. v rr resentntly . t'1 A . 3 EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 TYPE OF SERVICE REQUESTED: COMMENTS: fV 0 V J 3 Zoos SAN,JOAQUIN ENV! �Otj Ty HEAL-rH pEPAR w ACCEPTED BY: EMPLOYEE #: J DATE: ASSIGNED TO: EMPLOYEE#: 3 DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: fin Amount Paid Payment Date 10/31 D Payment Type S P invoice # Check # Received By: 3 EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003