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5255517888 Line 1 11-19:34 12-08-2015 3/9 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property er"LITY ID# SERVICE REQUEST# <br /> SERVICE STATION co Ct-f-"A� <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS[] <br /> FACILITY NAME <br /> ARCO-2186 <br /> SITE ADDRESS 3212 NCALIFORNIA STOCKTON 95204 <br /> Street Number I Direction Street NamA city Zip 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. 130S DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLINGADDRESS13 <br /> BUSINESS NAME PHO EXT. <br /> Gettler Ryan Inc. 551-7555 <br /> HOME or MAILING ADDRESS FAx# <br /> 6805 Sierra Court,Suite G ( 925) 551-7888 <br /> CIN 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,STATIE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:12/08/2015 <br /> PROPERTY/BUSINESSOwNF.R❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT AgentforOwner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 7 irie <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: Replacement 1e i Y <br /> COMMENTS: <br /> REPLACE INTERSTITIAL SPACE SENSOR, PART NUMBER 794390-409(LIKE FOR LIKE) IN EXISTING (+ <br /> TANKS. DErp g 10i5 <br /> SAN JO <br /> FiF ENVtr-�PAF'-rMENT pMQU/E COUWTy <br /> AL AL <br /> ACCEPTED BY: r�n,���� EMPLOYEE#: DATE: _ <br /> -� V <br /> ASSIGNED TO: EMPLOYEE#: DATE: i <br /> Date Service Completed (if already completed): SERVICE CODE: C P I E: <br /> Fee Amount: % Amount Paid _ Payment Date <br /> Payment Type �,(t/ Invoice# Check# Received r <br /> °, <br /> t—L <br /> EHD 48-02-025 SR FORM(Go] el*R ) <br /> REVISED 11/17/2003 '.I, i l <br /> PPAITFJ nr7oA0TKA',:KIT <br />