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9255517888 Line 13:11:07 08-17-2012 3x15 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 6773 s�o <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECKIfBILLINGADDRESS11 <br /> FACILITY NAME <br /> ARCO-2186 <br /> SITE ADDRESS 3212 N CALIFORNIA ST <br /> 95204 <br /> Street Number Direction Street Ci i 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 /> ( ) 125-320-01 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK If BILLING ADDRESS <br /> BUSINEss NAME Gettler Ryan Inc. PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 6747 Sierra Court,Suite J ( ) 551-7888 <br /> CIN Dublin STATE CA ZIP 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 fort-n. <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 F ERAL law . <br /> APPLICANT'S SIGNATURE: G DATE:08/17/2012 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/AAIAGER ❑ OTHER AUTHORIZED AGENT Cyl Agent for Owner <br /> If APPLICANT is not the BILLING PART)',proof Of authorization t0 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 FNVIRONMENTAL 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: COLD START <br /> COMMENTS: <br /> Need to cold start of the Veeder-Root System. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: P 1 E: <br /> Fee Amount: ,S Amount Paid �+� —> Payment Date <br /> W <br /> Payment Type Invoice# Check# Received By: <br /> 025 �trn - /� �, �J SR FORM(Golden Rod) <br /> REVISED <br /> 11/17/2003 <br />