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192 Main Fax GETTLER RYAN INC 0 10 P.M. 08-11-2008 3/11 <br /> 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 2 S �/`CO r. Cine <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO 2133 / <br /> SITE ADDRESS 2908 MIN HOLT DR STOCKTON 95207 <br /> Stre t Number Dir ion Street Nam2 city Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address] 6747 6747 Sierra Court,Suite J <br /> Street Number <br /> Street Name <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 C'95---(-: C' -V <br /> PHONE#2 Ext. BOS DISTRICT LOCATIOgCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Err, <br /> 925 <br /> Gettler Ryan Inc. 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: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DSPAR"rMENT 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 a ghat th ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN rY Ordinance Codtcv,Standards,STATE and DFR; .laws. <br /> APPLICANT'S SIGNATURE: DA'L'E: <br /> PRuvt:R'ry/BUSINESS OWNER❑ 0'1'IIER Au rnott[ZF.D A(.ENT ur Agent for Owner <br /> /f APPLu'.i:vT is not the BILLING tttt'Y,proq f of authorization to sign is required Title <br /> AIJ„THORIZATION 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 JOAQOIN COUNTY ENVIRON.MFNTAL I lI::A1:fFl DEPARTMEN'r 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 �j 1,1^L Y1 ; 1 / <br /> COMMENTS: G\J <br /> REPLACE POSITION SENSITIVE SENSOR REcG <br /> n <br /> N JOAOUIN NT L <br /> ACCEPTED BY: EMPLOYEE#: DATE: PART E� <br /> F LL G 1--_ � 3L <br /> ASSIGNED TO: f -AC K,. � EMPLOYEE#: 4 t,-L, DATE: f'' l G <br /> Date Service Completed (if already completed): SERVICE CODE: i q,?' P f E: 3(41 <br /> Fee Amount: ?�t S- t t.) Amount Paid '631 S uz� Payment Date (( p 8 <br /> Payment Type (Y\ Invoice# pCheck# Received By: - <br /> EHD 48-02-025 a� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />