Laserfiche WebLink
9155517888 Line 1 11-ng-Al a.m. 07-01-2009 3/13 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 6773 map / , <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO-2186 <br /> SITE ADDRESS 3212 N CALIFORNIA STOCKTON 95204 <br /> Street Number - <br /> Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court, Suite J <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925) 551-7555 125-320-01 <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Gettler Ryan Inc. PHOmr. 551-7555 EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> 6747 6747 Sierra Court, Suite J ( 9251 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 that the x6rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL a)vs. <br /> APPLICANT'S SIGNATURE: DATE:07/01/2009 <br /> PROPERTY/BUSINESS OWNER 13OPERATOR/NIANAGER OTHER AUTHORIZED AGENT Agent for Owner <br /> If APPLICANT is not the BILLING PARTY proof of 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it' <br /> provided to me or my representative. �E <br /> TYPE OF SERVICE REQUESTED: UST RETROFITloepm: <br /> Q <br /> COMMENTS:REPLACE POSITI <br /> ON SENSITIVE SENSOR (PART NO 794380-323)ON 87 MASTER FILL SUMP `h� <br /> A`TN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid -�3 S• O Paymen Date `I <br /> I <br /> Payment Type Invoice# h '^^ Check# Received By: <br /> EHD 48-02-025 �U 1"�Y`` �q�S SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />