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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 1t SERVICE REQUEST# <br /> SERVICE STATION V N p 2} <br /> OWNER/OPERATOR CHECK if BILLINGADDIRESSE-1 <br /> BP ARCO WEST COAST PRODUCTS LLC <br /> FACILITY NAME ARCO-2093 <br /> SITEAooREss 3425 TRACY BLVD. TRACY 95376 <br /> Code <br /> HOME or MAILING ADDRESS Of Different from Site Addrow) 6805 SIERRA COURT,SHITE G <br /> simeu rfitmgNang <br /> CITY STATE ZIP <br /> DUBLIN CA 54868 <br /> PHONE#I Exr. APN a LAND UsE APP1.icmior4 <br /> ( 925 ) 551.7555 i <br /> PHONE 172 Em SOS DISTRICT LOCATI1 1 IOO,N Com <br /> ( 11 1 co 1 LJ <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BERLIN BOWEN CHECK If 131y,yi © <br /> BUSINESS NAME Gettler Ryan Inc. PHONE5 551.7555 ENT. <br /> HOME or MAR NG ADDRESS FAX I <br /> 6805 SIERRA COURT,SUITE G ( 925 ) 551.7888 <br /> CRY DUBLIN STATE CA LP 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 /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDS. <br /> APPLICANT'S SIGNATURE:�CL `Z� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATORIMANAGER ❑ OTFtERAUTHORIZED AGENTAgentforOwner <br /> IfAPPL"Nr IRs not the BILLING PARTY proof of authorization to sign Is required Thle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator t 1rt <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or, t (e; sinformation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTFI DEPARTMENT as soon as it is avai bt e same time it is <br /> provided to me or my representative. S E Ps 7 <br /> TYPE OF SERVICE REQUESTED: REPLACEMENT OF 208 SENSOR IN L5 STP SUMP WITH SAME <br /> COMSNENTS: FPIVIR ' <br /> REMOVED BAD 208 SENSOR IN L5 STP SUMP WITH A VEEDOR ROOT 208 SENSOR.CONFIRM NEW SENSOFHMN lRg-pAJjTffN f <br /> ACCEPTED BY: G �r A.- EMPLOYEE 0: no,COa 3 DATE: 9y 21 1 ((a <br /> ASSIGNED TO: Ock�-1`-"� EMPLOYEE B: ��00 0 OO 3� DATE: q }211100 <br /> Date Service Completed (it alroady completed): SERVICE CODE: 1 1 P I E:d?�dt <br /> Fee Amount: L S .G� Amount Pai 'f.�b.o� Payment Date ` <br /> Payment Type ek Invoice F Check 8 j-4g3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />