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' }9255517888 Main Fax GETTLER RYAN INC 5:29 p.m. 09-07-2007 3/6 <br /> SAN JOAQUIN IUNTY ENVIRONMENTAL HEALTH DIARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION FA,a0U,;l¢v4; <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO 2133 <br /> SITE ADDRESS 2908 BENJA HOLT DR STOCKTON 95207 <br /> Street Number I Dire tin I Street Name I city Zip Cod <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 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE4 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEy PHONE# EXT. <br /> Leffler Ryan Inc. 925 551-7555 <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 a performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED•R <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 10 Agent for Owner <br /> IfAPPL1CANT 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 is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT ` AYMENT <br /> COMMENTS: <br /> START-UP MONITORING SYSTEM SEP 7 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: li+ I <br /> r1 EMPLOYEE#: (/�(SS DATE: <br /> ASSIGNED TO: 11 Irn EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: �U P I E: 0$ <br /> Fee Amount: n fi� -� Amount Paid D� Payment Date Cl I1 b 9 <br /> Payment Type V� Invoice# Cec'k# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 712 003 <br />