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9255517888 Line 11 ?9:45a.m. 06-05-2009 2/8 <br /> 1 ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIL <br /> IT�YID# SERVICE REQUEST# <br /> SERVICE STATION 6773 <br /> /73 SR0057382 <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK If BILLINGADDRESS� <br /> FACILITY NAME <br /> ARCO-2186 <br /> SITE ADDRESS 3212 NCALIFORNIA STOCKTON 95204 <br /> Street Number Direction Street Name city ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court, Suite J <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 125-320-01 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHO Ext. <br /> 551-7555 <br /> HOME Or MAILING ADDRESS FAx# <br /> 6747 6747 Sierra Court, Suite J ( 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 work to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE laws. <br /> APPLICANT'S SIGNATURE: DATE: 6/05/2009 <br /> PROPERTY/BUSINESS OWNER OPERA /MANAGER it- OTHER AUTHORIZED AGENT 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 environmentaUsite 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. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: <br /> REPLACE POSITION SENSITIVE SENSOR (PART NO 794380-323)ON 91 T3 FILL SUMP <br /> INSTALL AUDIOVISUAL EXTERNAL ALARM (VEEDER-ROOT#790091-001, SN: 063651) <br /> REPLACED FOUR-RELAY OUTPUT INTERFACE MODULE (VEEDER-ROOT#329359-001) <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />