Laserfiche WebLink
19255517888 Main Fax • GETTLER RYAN INC 03_45:30 p.m. 06-06-2007 216 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 0 0 p <br /> OWNER 1 OPERATOR <br /> CHECK if BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO 2133 <br /> SITE ADDRESS 2908 BENJAMIN HOLT DR STOCKTON 95207 <br /> treat Number 1311Mn Street Name city zip CO" <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court,Suite J <br /> Strapt Number Street <br /> CITY STATE zip Dublin CA 94568 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 - ?/ <br /> PHONE 92 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKEN2:IE CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT.Ryan Inc. 925 551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 I 6747 Sierra Court,Suite J ( 925 ) 551-7888 <br /> CITY Dublin I 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 t rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F E w <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA ANAGER ❑ OTHER AUTHOR1zED AGENT W Agent for Owner <br /> 1fAPPucANT is not theB&L MGPARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RRLEASE 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 ENv1RONMENTAL HEALTH DEPARTMENT as soon as it is availab] e time it is <br /> provided to me or my representative. ED <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: JUN <br /> START-UP MONITORING SYSTEM SAN JOAQUIN COUNT`! <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: /C� J D Amount Paid <br /> S Payment Date L <br /> Payment Type AAW % Invoice# Check# Received By: "L,, � <br /> EHD 48-02-025 <br /> lam'— �S I,,, SR FORM(Golden Rod) <br /> REVISED 11/17/2003 C, <br />