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9255517888 Line 1� � ;39:40 06-15-2015 4110 <br />:. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTiVIEW j' <br />SERVICE REQUEST ' <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE R@Mq#5 2 01 <br />SERVICE STATION <br />CHECKit BILLING ADDRESS <br />--;5 Le Cf 1�-I) <br />SIL 067aq <br />OWNER i OPERATOR <br />ExT. <br />s <br />ElP West Coast Products LLC <br />CHeCKIf IL'LING <br />FACILITY NAME ARCO 9821841 <br />SIrEADDREss <br />7611 g AIRPORT WAY <br />STOCKTON 85206 <br />treat Number <br />a G 21 Code <br />HOME or MAIIJNG ADDRESS (If Different from Site Address) <br />STATE CA <br />6805 <br />Sierra Court, Suite G <br />DATE: <br />Street Number Street Narne <br />CITY <br />STATE <br />STATE ZIP <br />Dublin <br />94508 <br />PHONE #•I Ev. APN * <br />LAND USE APPLICATION # <br />( 925 ) 551-7555 <br />✓ <br />PRONE #2 Exr• <br />{ 1 <br />BOS DISTnICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR LIDDY MCKENZIIE <br />CHECKit BILLING ADDRESS <br />BUS1NE85 NAME 'Settler Ryan Inc. <br />M <br />PHONE# <br />ExT. <br />925 <br />551-7555 <br />HOME or MAILING ADDRESS <br />FAX# <br />6665 Sierra Court, Suite G <br />( 925' <br />551-7888 <br />CITY Dublin <br />STATE CA <br />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 />TAL. <br />�r,J- <br />I also certify that I have prepared this application and that the work to be performed ill be done in accordance with all SAN JOAQL72N <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ATE: � l/ <br />PROPERTY/ BUSINESS OWNERO OPERATOR/ MANAGE �HERAUTHOIZIZED AGENT i�p Agent for Ow er <br />IfAPPL1CrtNT is not the BILWNG PARTY proof of authorization to sign Ls 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 enviromnental/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. A <br />TYPE OFSERViCEREQUESTED: COLA START �� R ��4 <br />COMMENTS: �I vFQ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712003 <br />A 5 <br />LQ�'tC� <br />M <br />EXISTING TLS 350 CONSOLE WAS IN A WARM START LOOP, HAD TO COLD START THE CONSOLE. <br />SAv,�o�Q <br />He4��0A <br />ACCEPTED BY: <br />EMPLOYEE is <br />DATE: <br />AssIGNED TO: wl z C <br />EMPLOYEE C <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: j <br />Pia:: <br />PFe:9:A:Ho:u:n:1: C Amount P I 3<7Q <br />11 luymentType <br />Payment Date <br />�SS- <br />✓ <br />invoice# <br />Ch #�� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712003 <br />A 5 <br />LQ�'tC� <br />