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SAN.TOAQUIN t;OUNTY ENVIRONMENTALH EALT HLEPARTMEN T <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station {Z 'G S'jeo(� � 3 Q/ <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESSO <br /> FACILITY NAME Arco 5450 <br /> SITE ADDRESS 1617 W. Fremont Street Stockton 95203 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address)3 Centerpoint Drive <br /> Street Number Street Name <br /> CITY La Palma STATE Ca. ZIP 90623 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (530 )621-0770 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Randy Brown CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Gettler-Ryan Inc. (925)551-7555 <br /> HOME or MAILING ADDRESS FAx# <br /> 6747 Sierra Court Suite J (925 )551-7888 <br /> CITY Dublin STATE Ca ZIP 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 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,STAT FEDERAL laws. <br /> APPLICANT'S SIGNATUR DATE: September 14, 2011 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Service Manager <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. n - <br /> TYPE OF SERVICE REQUESTED: Permit Approval t't...S IT 1�—�"j7��i Ft-r P Elof en <br /> COMMENTS: <br /> SEP 15 2011 <br /> Replace faulty Probe in 87 slave tank. 5'" Ro EKTX� <br /> �TM oE?ARTrtW <br /> ACCEPTED BY: QLt v>`t EMPLOYEE#: DATE: T S / <br /> ASSIGNED TO: C v EMPLOYEE#: 1 t�Z� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / PIE: tel} <br /> Fee 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 />