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SAN JOAQUIN COUNTY ENVIRONMENTAL EALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Arco 5450 <br /> SITE ADDRESS 1617 W. Fremont Street Stockton 95203 <br /> Street Number AM NameCox Mg Code <br /> HOME or 11NAium ADDRESS of Dillerent from site Address)3 Centerpoint Drive <br /> Street Number 3treet Name <br /> CITY La Palma STATE Ca. zlP 90623 <br /> PHONE#1 EXT. APN/ LAND USE APPuCA noN# <br /> (530)621-0770 <br /> PHONE#Z ExT• SOS DISTRICT LOCATION CODE <br /> { 1 <br /> CONTRACTOR!SERVICE UEST <br /> EQUESTOR Randy Brown CHECK if BILLING ADDREgs <br /> BUSINESS NAME Gettler-Ryan Inc. 1925 551-7555 <br /> HOME or MAILING ADDRESS 6747 Sierra Court Suite J (s s )551-7888 <br /> CITY Dublin STATE Ca zIP 568 <br /> ELLIDIra AC ENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE; September 14,2011 <br /> PROPERTY/BUSINESS OWIVER13 OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ Service Manager <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> A H0RI TION IQ RKLEAEE INFO ATI N: 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. PP <br /> TYPE OF SERVICE REQUESTED: Permit Approval L.(sT 7,e.5 F—t T- 1VF-0 <br /> COMMENTS: <br /> ISEP <br /> 15 211 <br /> Replace faulty Probe in 87 slave tank. ` �,,,MW)NM�u <br /> p tY �„RONxE�r <br /> VOLV DEIOTKEW <br /> ACCEPTED BY: 0(- v�t EMPLOYEE#: .Z DATE: ,5P-• , <br /> ASSIGNED TO: L v EMPLOYEE#: 1 t Z„/ DATE: 4 1-5-11( <br /> Date Service Completed (N already completed): SERVICE CODE: 14 - PIE: 22n s' <br /> F Amount: $375.00 Amount Paid $375 00 Payment Date September 14,2011 <br /> Payment Type Credit Card Invoice Check# Received By: <br /> Confirmation #A54056 ✓ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />