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19255517898 Main Fax GETTLER RYAN INC '14 p.m. 04-23-2008 3112 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# /SERVICE REQUEST# <br /> SERVICE STATION (` C" 5��O5-1 i z <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> SP West Coast Products LLC <br /> FACILITY NAME ARCO 5450 <br /> SITE ADDRESS 1617W FREMONT ST STOCKTON 95203 <br /> Street Number D rection I 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#t ExT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 /35— 1 CJ — 1 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR J SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE CHECKifBILLING ADDRESSIZI <br /> BUSINESS NAMEPHONE# EM' <br /> Gettker Ryan Inc. 925 551.7558 <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: 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 e w o d will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED L <br /> APPLICANT'S SIGNATURE: DATE: -4 <br /> Z� 3/0 <br /> PROPERTY/BUSINESs OWNER❑ OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT W Agent for Owner <br /> IfAPPLICANT is not theB/LLwGPARTY.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 c-time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT Rte` <br /> COMMENTS: <br /> REPLACE RED JACKET(P/N 116-056-05)IN THE 91 STP SUMPP� CpuN <br /> r1 JCI'QUNMEN�PEt1 <br /> SH�`�N p�PpK�M <br /> ACCEPTED BY: �{i ( -l j r ( --�} EMPLOYEE M C) 3 2 DATE: <br /> ASSIGNED TO: V o/•.i -F kut C--. EMPLOYEE M F3 (-7 DATE: 41 C% <br /> Date Service Completed (if already completed): SERVICE CODE: l r -=PIE:Ii <br /> L <br /> Fee Amount: � , Amount Paid } Payment Date Lk 23 <br /> Payment Type a51� .0 Invoice# Qbeo# 5 3 1 �' Received By: <br /> EHD 48-02-025 urk SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />