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9255517888 Line 1 15 p.m. 10-31-2008 2/3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION C; <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO 5450 <br /> SITE ADDRESS 1617 W FREMONT ST STOCKTON 95203 <br /> Street Number I Direction Street Name city Zip Code <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 Exr. BOS DISTRICT rR LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR f� <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS IZI <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# 551-7555 Exr. <br /> 925 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 6747 Sierra Court,Suite J ( 925 ) 551-7868 <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 for . <br /> I also certify that I have prepared this application an hat the w be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F DERAL 1 <br /> APPLICANT'S SIGNATURE: DATE: O / O <br /> PROPERTY/BUSINESS OWNER 13 OPERA R/ R I] OTHER AUTHORIZED AGENT 1Z Agent for Owner <br /> If 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: UST RETROFIT I'AYMENT <br /> COMMENTS: <br /> REPLACE SENSOR(P/N 794380-344)ON 91 FILL SUMP NOV 3 2008 <br /> SAN JOAQUIN COUNTY <br /> NENVIRON�K. <br /> HEALTH DE AR�' <br /> ACCEPTED BY: [_ t✓ C EMPLOYEE#: C) Z DATE: <br /> ASSIGNED TO: (_Lk E_ EMPLOYEE#: IF / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: l�� P E: <br /> Fee Amount: 3 cS F,� Amount Paid st Payment Date ` 3 b <br /> Payment Type v Invoice# C#ec" o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />