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SAN JOAQUIrN COUNTY ENVIRONMENTAL HEALTI�EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station X 773 S&0(1;36/—_. <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLINGADDRESSO <br /> FACILITY NAME Arco 2186 <br /> SITE ADDRESS 3212 N. California Street Stockton 95204 <br /> Street Number Direction Street Name City i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)4 Centerpoint Drive <br /> Street Number Street Name <br /> CITY La Palma STATE Ca. ZIP 90623 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (530 )621-0770 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Randy Brown CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Gettler-Ryan Inc. (925)551-7555 <br /> HOME Or MAILING ADDRESS 6747 Sierra Court Suite J 25 )551-7888 <br /> CITY Dublin STATE Ca Z'P 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. <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, STAT FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: Ocober 5, 2011 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR TANAGER ❑ OTHER AUTHORIZED AGENT❑ Service Manager <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 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: Permit Approval PAYMENT <br /> COMMENTS: <br /> OCT -6 2011 <br /> Replace faulty sensor in 91 STP Sump. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L e E EMPLOYEE#: % (� DATE: <br /> ASSIGNED TO: 13,4 c/ S. EMPLOYEE#: 4�J DATE: %6 �1 <br /> Date Service Completed (ifalreadycompleted): SERVICE CODE: P i E: <br /> Fee Amount: $375.00 Amount Paid $375.00 Payment Date October 5, 2011 <br /> Payment Type Credit Card Invoice# Check# Received By: n , <br /> EHD 48-02-025 Confirmation #A45628 SR FORM(Golden Roo <br /> REVISED 11/17/2003 <br />