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SAN JOAQU*1OUNTY ENVIRONMENTAL HEALTH _ ZPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 15 �3 C <br /> OWNER/OPERATOR <br /> BP ARCO WEST COAST PRODUCTS LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ARCO-2186 <br /> SITE ADDRESS 3212 In CALIFORNIA STREET STOCKTON 95204 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT,SUITE G <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 11,552001 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> Gettler Ryan Inc. 925 551.7555 <br /> HOME or MAILING ADDRESS FAx# <br /> 6805 SIERRA COURT,SUITE G ( 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 rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and PEDE aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OftiiATOR/MANAGER ❑ OTHER AUTHORIZED AGENT V Agent for Owner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tit ft <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the propabove site address, hereby authorize the release of any and all results, geotechnical data and/or environme /site <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a *aryime it Is <br /> provided to me or my representative. % 20 <br /> TYPE of SERVICE REQUESTED: OVERFILL VALVE INSTALLATION 'Y�A4�tRONINCOU <br /> COMMENTS: Af?,. r <br /> REMOVE EXISTING DROP TUBES AND VENT BALL FLOAT CAGES AND INSTALL NEW OPW-71SO OVERFILL PROTECTION VALVES <br /> �fJ <br /> ALL LISTS <br /> D <br /> ACCEPTED BY: I, MCLA <br /> EMPLOYEE#: DATE: q. I <br /> ASSIGNED TO: S , ���� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Pai [���� U Payment Date 9�3 <br /> Payment Type Invoice# Check# f`t77 ecei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />