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19255517888 Main Fax • GETTLER RYAN INC 12 10 p.in. 03-05-2007 2112 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ,� 6, <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY2ID# +J r� SERVICE REQUEF# <br /> SERVICE STATION {C�Qc71� /L 5 /a ouqvL <br /> OWNER/OPERATOR CHECK If BILLING ADDREss❑ <br /> BP WEST COST PRODUCTS <br /> FACILITY NAME ARCO-9600__ <br /> SITEADDRESS 1250 V N WILSON WAY STOCKTON 95205 <br /> Street Number treat Name ZIP Coae <br /> How or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court, Suite J <br /> Street Number Street Name <br /> Cm Dublin STATE CA ZIP 94568 <br /> RHONE#I Exi. APN# LAND USE APPLICATION# <br /> ( 925) 551-7555 <br /> PHONE 02 En. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESSm <br /> BUSINESS NAME PNONE# EXT. <br /> Ryan Inc. s2s 551.7555 <br /> HOME or MAILING ADDRESS 6747 Sierra CourtSuite J Fm# <br /> ( 925 1 551-7888 <br /> CITY Dublin STATE CA 21P 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL 1 S. n <br /> APPLICANT'S SIGNATURE: DATE:t 7 � � <br /> PROPERTY/BUSINESS OWNERM OPERATOR/11 NAGER rW <br /> OTHER AUTHORIZED AGENT Agentfor Owner <br /> IfAPPLICANTis not the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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.%4 rtrle time it is <br /> provided to me or my representative. `(ME <br /> TYPE OF SERVICE REQUESTED: S- RE <br /> COMMENTS: MAR — 5 T <br /> REPLACE 89 TURBINE SENSOR(PART NO. 794380-323) SpJENV PONMEGooto <br /> NTM to <br /> HSWIF1 DEPPRT If <br /> ACCEPTED BY: EMPLOYEEM DATE: <br /> ASSIGNED TO: MNkCk EMPLOYEE III: DATE: <br /> Date Service Completed (if already mpleted): SERMCE CODE: PIE: v <br /> V I <br /> Fee Amount: mount Paid �'$, Paymen Date 3 a-7 <br /> Payment Type rn ��Alnvoic�ie# �{. Check# Received By: <br /> EHD 48-02-025 l.P�• A 1 �� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />