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92 55 51 7888 LIne1 11.0, `a.rtt. 06-01-2016 3!11 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUESVN 01 2016 <br /> Type of Business or Property FACILITY a10 r►n o a1, SERVICE REQUEST# <br /> SERVICE STATION Sem-l`tq <br /> OWNER/OPERATOR <br /> SP West Coast Products LLC CHECK if BILLING ADORESS❑ <br /> FACILITY NAME ARCO 2186 <br /> SITE ADDRESS 3212 N CALIFORNIA STOCKTON 95204 <br /> Street Number Qir tlon StreatName cityCode <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 IZ� �Q <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK If BILLING ADDRESS <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 /> I also certify that I have prepared this application and that the work to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1l/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M ER OTHER AUTHORIZED AGENT V Agent for Owner <br /> If APPLICANT is not the BILLING P .P of 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 IV�CO <br /> COMMENTS: <br /> PENETRATION FITTING REPLACEMENT AND SB989 RETEST OF UDC#5-6. yoMD,� <br /> A'>Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: 8 PIE: 2-141L I g <br /> Fee Amount: 1 OD Amount Paw3 0,00 Payment Date / <br /> Payment Type ✓$' Invoice# C ck# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />