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. SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Gas Station � �leao/034i/ OWNER/OPERATOR BP West Coast Products LLC CHECK if BILLING ADDRESS FACILITY NAME Arco 5450 SITE ADDRESS 1617 W Fremont Street Stockton 95203 Street Number Direction Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address)4 Fenterpoint Drive Street Number Street Name CITY La Palma STATE Ca. ZIP 90623 PHONE#1 ExT. APN# LAND USE APPLICATION# (530)621-0770 PHONE#2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Randy Brown CHECK if BILLING ADDRESS BUSINESS NAME E Gettler-Ryan Inc. PHONE# 925-551-7555 HOME Or MAILING ADDRESS 6747 Sierra Court Suite J � # )925-551-7888 CITY Dublin STATE Ca ZIP 94568 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE a FEDERAL laws. APPLICANT'S SIGNATURE: DATE: October 5, 2011 PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Service Manager LfAPPL/CANT is not the BILLING PARTYy_proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Permit Approval PAYM COMMENTS: Replace faulty sensor in 91 fill sump. SAN�OAQUINcoUNTr HEWFIONMENT &-TM H&-TM ACCEPTED BY: Lowe EMPLOYEE#: p DATE: j G C7 ASSIGNED TO: 1t'✓eT'+ EMPLOYEE#: / DATE: r0 r Date Service Completed (if already completed): SERVICE CODE: M P/E:,23 p8 Fee Amount: $375.00 Amount Paid $375.00 Payment Date October 5,2011 Payment Type Credl Card Invoice# Check# Received By: Confirmation #X55 A 4-l 1 EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003 C')