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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />AMMM <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station <br />I <br />I <br />Sc cr 4, q q T 9 <br />OWNER /OPERATOR <br />CHm"W1°Anown13 <br />BP West Coast Products LLC <br />FAcltm NAME Arco 2093 <br />DATE <br />SITE ADDRESS 3425 <br />Tracy Blvd <br />I <br />Tracy <br />95376 <br />ftye <br />$375.00 <br />Payment Data December 23, 2011 <br />Payment Type Credit card <br />cfty <br />Zip <br />HOME or MAULING ADDRESS (If Different from Site Aditss) 4 <br />Centerpoint Drive <br />S <br />Nuntw <br />3blet Name <br />crrY La Palma <br />STATE Ca. 2,P 90623 <br />PHONE #1 Exr• <br />APN # <br />LAND USE APPuCAnom 0 <br />(530)621-0770 <br />PHm #2 EXT. <br />( ) <br />BOS DNTTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />Randy Brown <br />AMMM <br />BUSINESS NAME <br />Inc. <br />CoMMaas: <br />Replace faulty ECPU Board. <br />P"WGettler-Ryan # )925-551-7555 <br />HOME or MAULING ADDRESS <br />6747 Sierra Court Suite J <br />ACCEPTED Sr. ��� <br />FAK# <br />( )925-551-7888 <br />CITY Dublin <br />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 form. <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 JoAQum <br />COUNTY Ordinance Codes, Standards, STATE EDERAL laws. <br />APPLICANT'S SIGNATU DATE: February 29, 2012 <br />PROPERTY/BUSINESS OWNER OPERATOR/MANAGERO OTHERAUTHoR17EDAGENT <br />�ServiCeManager <br />1f APPLICANT 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 environmental/site 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: Permit Approval kz, -F <br />12. ---mo r <br />CoMMaas: <br />Replace faulty ECPU Board. <br />RECEIVED <br />FEB 2 9 2012 <br />SAN JOAQUIN COUNTY <br />NVIROMENTAL <br />ACCEPTED Sr. ��� <br />EMPLOYEE #: l <br />HEf JA*DEP ^rff <br />ASSIGNED TO: <br />EMPLOYEE #: !�� <br />DATE <br />Dab Service Completed (K already completed): <br />Saw= Coots <br />v/ <br />PIE: 2- pe <br />Fee Amount: $375.00 <br />1 Amount Paid <br />$375.00 <br />Payment Data December 23, 2011 <br />Payment Type Credit card <br />Invoice # <br />Check # <br />Received By: <br />Confirmation # A45399 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />