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9255517899 Line 1 11—140 a.m. 06-15-2010 2/6 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT . <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 6773 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO-2186 <br /> SITE ADDRESS 3212 1 N CALIFORNIA STOCKTON 95204 <br /> Street Number Direction Street Name Ci Z ip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 67476747 Sierra Court, Suite J <br /> Street Number Street Name <br /> CITY STATE zip <br /> Dublin CA 94568 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 925) 551-7555 125-320-01 <br /> PHONE#2 Ext. BOS DISTRICT . LOCATION CODE <br /> ( ) I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# ExT• <br /> 925 551-7555 <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERA aws. <br /> APPLICANT'S SIGNATURE: DATE:06/15/2010 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR ANAL OTHER AUTHORIZED AGENT I;r 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 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: UST RETROFIT PAYMENT <br /> COMMENTS: RECEIVED <br /> SWITCHED PROBE FROM T1 TO T2. JUN 17 2010 <br /> SAN JOAQUrN CouNrr <br /> ENYI RO N M ENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: G1( VAC i Ae? ; EMPLOYEE#: O3 21-1 DATE: <br /> ASSIGNED TO: �f�� s EMPLOYEE#: �/W 3 6 DATE: 7 1 <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: —4 S" O"J Amount Paid 3 s Payment Date (o / <br /> Payment Type A\ e Invoice# Etc# pXQn,,-Jt R (7 p Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />