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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH"IEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station �7� Sle,bo, s <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Arco 2186 <br /> SITE ADDRESS 3212 N. California Street Stockton 95204 <br /> Street Number I Direction Street Name C ity Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address)4 IC <br /> enterpoint 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 /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Randy Brown CHECKifBILLINGADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Gettler-Ryan Inc. (925)551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; May 24, 2011 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Service Manager <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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Permit Approval �O <br /> COMMENTS: <br /> Replace faulty sensor in Dispenser UDC #1812. <br /> ACCEPTED BY: EMPLOYEE DATE: p <br /> ASSIGNED TO: EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERwc CODE: P <br /> Fee Amount: $366.00 Amount Paid $366.00 Payment Date May 24th 2011 <br /> Payment Type Credit Card Invoice# Received By: <br /> Confirmation #A39326 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />