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9255517888 Line 09:17:30 06-22-2015 4/12 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION F- 'o'= � �� <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS[]BP West Coast Products LLC <br /> FACILITY NAME ARCO 5450 <br /> SrIEADDREss 1617 W FREMONT STOCKTON 95206 <br /> Street Number Direct n e Name Ci tcotle <br /> HOME or MAILING ADDRESS (if Different from Site Address) 6805 Sierra Court,Suite G <br /> Street Number StreetName <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE V ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR L.IDDY MCKENZIE CHECK If BILLING ADDRESSla <br /> BUSINESS NAME Gettler Ryan Inc. PHONE 5 551-7555 EXT. ;`I,SIV <br /> HOME or MAILING ADDRESS FAX# E� <br /> 6805 Sierra Court,Suite G ( 925 ) 551-7888 JUN <br /> 22015 <br /> CITY Dublin STATE CA Zip 94568 �o 0,� <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of satlf �'ti,17y <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project &VT <br /> or activity will be billed to me or my business as identified on thi form. <br /> I also certify that I have prepared this application and that t ork to be performed will be done in accordance with all SAN JOAQUIN <br /> CouNTY Ordinance Codes,Standards,STATE and FEDE aws <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE R/MANAGER E3 OTHER AUTHORIZED AGENT Er 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 <br /> VED <br /> provided to me or my representative. R <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: 015 <br /> REPLACE ANNULAR SENSORS IN ALL TANKS WITH VR PART NUMBER 794390-409.."LIKE FO_,� iONM NTAL <br /> 1V .. �.. 14 Rcerr <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: �(P <br /> ASSIGNED To:t� P—C vC+J� EMPLOYEE#: DATE: C) • 1 <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: <br /> Fee Amount: ljclo-OL) Amount Paid d 1jQ Payment Date 1S <br /> Payment Type I Invoice# C ak# Recely d By: <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />