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9255517888 Line 1 0'----56 p.m. 02-11-2009 3/12 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS CI <br /> FACILITY NAME ARCO-2186 <br /> SITE ADDRESS 3212 N CALIFORNIA STOCKTON 95204 <br /> Street Number Direction I Street Name city Zip 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 Eur. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 /,7-57- 32G -c; <br /> PHONE#2 EXr• BOS DISTRICTLOCATION CODE <br /> ( l <br /> 1� 7 / <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# 551-7555 Exr <br /> 925 <br /> HOME Or MAILING ADDRESS FAX# <br /> 6747 6747 Sierra Court,Suite J ( 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: `-� DATE: L ��` C? <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1Z Agent for Owner <br /> If Ap,pLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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 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. T <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT CE�VE <br /> COMMENTS: 1 2Q <br /> REPLACE POSITION SENSITIVE SENSOR (PART NO 794380-323)ON 87 FILL SUMP cou FEB1 <br /> SAND JO RONMEW NT <br /> H�-P.{pEPP'B <br /> ACCEPTED BY: EMPLOYEE#: �,j Z t DATE: <br /> ASSIGNED TO: 'J K t S EMPLOYEE#: F-(�'-> DATE: Z <br /> Date Service Completed (if already completed): SERVICE CODE: (,57gi <br /> Fee Amount: j( _ �,, Amount Paid 31,S Payment Date <br /> Payment Type Invoice# CheCR It 2 c'S -2 Rec <br /> aeived By: tV C,_, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />