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SAN JOAQUIiv COUNTY ENVIRONMENTAL HEALTH iJEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station Arco-248$— (�? 3 5X-op 6oP3 Y 7 <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK If BILLINGADDRESS� <br /> FACILITY NAME Arco 2186 <br /> SITE ADDRESS 3212 1 N. I California Street Stockton 95204 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address)4 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 6747 Sierra Court Suite J 25 )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 /> 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,ST d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: September 14, 2011 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Service Manager <br /> IfAPPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: Permit Approval Li-&T- 4-F— 6 F tT_ PAYMEN <br /> COMMENTS: <br /> SEP � 5 2011 <br /> Replace faulty Red Jacket Transducer in 91 Turbine. SAS JC) <br /> AnutscourrrY <br /> F W?'oN MENTAL <br /> HEAI-Tti DE.PARTMEHT <br /> ACCEPTED BY: EMPLOYEE#: n DATE: q it <br /> ASSIGNED TO: �Lr S EMPLOYEE#: ♦ 3 DATE: C� 1 (S U <br /> Date Service Completed (if already completed): SERVICE CODE: r P I E: 0 �- <br /> Fee Amount: $375.00 Amount Paid $375.00 Payment Date September 14, 2011 <br /> Payment Type Credit Card Invoice# Check# Received By: 14� <br /> Confirmation #A45662 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />