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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION T- 00D3b®b SIZOQ 79& 56 <br /> OWNER/OPERATOR <br /> BP ARCO WEST COAST PRODUCTS LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ARCO-5450 <br /> SITE ADDRESS 1617 S FREMONT STOCKTON 95203 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT,SUITE G <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> DUBLIN CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551.7555 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK if BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONE#925 551.7555 ExT <br /> HOME or MAILING ADDRESS FAx# <br /> 6805 SIERRA COURT,SUITE G ( 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 th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FERE laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Agent for Owner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required T A <br /> iv <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the propTifte <br /> e <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmeJfFasse t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atZ17e s�tl tq�� it is <br /> provided to me or my representative. --JO <br /> TYPE OF SERVICE REQUESTED: OVERFILL VALVE INSTALLATION yEAL7RONMFN IJAfry <br /> COMMENTS: ENT <br /> REMOVE EXISTING DROP TUBES AND VENT BALL FLOAT CAGES AND INSTALL NEW OPW-71 SO OVERFILL PROTECTION VALVES IN <br /> ALL LISTS <br /> ACCEPTED BY: t I w EMPLOYEE#: DATE: QP 041 <br /> ASSIGNED TO: I\�� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C P E:v ,(� <br /> Fee Amount: Amount Pai (o,U v Payment Date ,? l/ <br /> Payment Type Invoice# Check# 140 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />