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92 55 51 7888 Line 1 08:04•_r,a.m. 04- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APR 0 4 2016 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQuES11A I ENTAL <br /> SERVICE STATION r <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO 2186 <br /> SITE ADDRESS 3212 N CALIFORNIA STOCKTON 95204ZipCods <br /> Street Number Direction Street Name i 2i <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 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE <br /> CHECK if SLING ADDRESSIZ <br /> BUSINESS NAMEGPHONE# Err. <br /> ettlerRyan 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: 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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: <br /> _f�4/)� <br /> PROPERTY/BUSINESS OWNER❑ OPF, IAItiA 'R ❑ OTH$RAL'THORIZEDAGENT Agent for Owner <br /> If APPLICANT is not the NG 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 environmentaUsite assessmAt <br /> infomTation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time , yti1E <br /> provided to me or my representative. FC�CiV�O <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: N✓OgQu ?O <br /> COLD START REQUIRED DUE TO POWER BROWN OUT F�`� �F A ti ti <br /> a <br /> ACCEPTED BY: , EMPLOYEE#: DATE: <br /> XA Irv, <br /> ASSIGNED TO: Z—ar-" EMPLOYEE M DATE: _ r/ <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: 230 <br /> Fee Amount: ( U Amount Pai J /0 �� Payment Date 4 <br /> Payment Type Invoice# Ch # Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />