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SAN JOAQUIN,, OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CH K If BILLING ADDRESS <br /> FACILITY NAME ARCO 2186 <br /> O <br /> SITE ADDRESS 3212 N CALIFORNIA STOCKTON 95204 <br /> Street Number I Direction I Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 Sierra Court,Suite G <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 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE CHECK if BILLING ADDRESSID <br /> BUSINESS NAMEPHONE# EXT. <br /> Gettler Ryan Inc, 925 551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 6805 Sierra Court,Suite G ( 925 ) 551-7888 <br /> CITY Dublin STATE CA ZIP 94568 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 tha work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FED law <br /> APPLICANT'S SIGNATURE: DATE: �s <br /> PROPERTY/BUSINESS OWNER❑ QPEOR/MANAGER OTHER AUTHORIZED AGENT V Agent for Owner <br /> IfAPPLICANT is 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 environmeTeelfl, <br /> assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ai firprovided to me or my representative. 1 1 <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT uEC D 9 <br /> COMMENTS: AN JOAQIJIN <br /> REPLACE DISPENSERS WITH NEW DRESSER WAYNE BLENDING DISPENSERS AND HANGING H OMEN Co <br /> CONVERT PHASE II EVR �LPAfJtjWEN <br /> T <br /> FROM VAC ASSIST VR-202 TO BALANCE SYSTEM VR-204. REPLACE TURBINES WITH NEW FE PETRO. <br /> ACCEPTED BY: EMPLOYEE#: DATE: /Z, (� / <br /> ASSIGNED TO: �^ EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed: SERVICE CODE: Q S( P 1 E2 <br /> Fee Amount: bc� Amount Paid 39 p Payment Date ) '9 S <br /> Payment Type Invoice# Check# X23 Received By: N.� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />