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SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTh L EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 6773a/` 00 CpS 4 �- <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK If BILLINGADDRESS� <br /> FACILITY NAME <br /> ARCO-2186 <br /> SITE ADDRESS 3212 N CALIFORNIA STOCKTON F95204 <br /> Street Number Direction Street Name city i 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 DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK If BILLINGADDRESSO <br /> BUSINESS NAME Gettler Ryan Inc. ( EXT. <br /> 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. kx-o I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAtd��6AAyI� <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. N� ` <br /> r <br /> APPLICANT'S SIGNATURE:-,' '��. Cij DATE:11/05/2013 ,.,l � O1�jti <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT q Agent for Owner H �iRoN <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 <br /> COMMENTS: <br /> REPLACE EXISTING OPW SPILL BUCKETS DEFECTIVE PARTS WITH SAME AND REPLACE EXISTING UST <br /> SUMP SENSORS WITH 208 SENSORS. <br /> ACCEPTED BY: 14,1 r EMPLOYEE#: G,6 2 0 DATE: 1 (/-7 10 <br /> ASSIGNED TO: u EMPLOYEE#: 3 DATE: i( 7 f t3 <br /> Date Service Completed (if already completed): SERVICE CODE: / y PIE: -3 U <br /> .11 Fee Amount: 39 5 c o Amount Pai 3715 Payment Date / 0 <br /> Payment Type Invoice# Check# Y3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />