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0 <br />e <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />/ <br />�'� <br />SERVICE REQUEST # <br />Gas Station <br />Arco 2133 <br />i� <br />.SS"o <br />OWNER /OPERATOR <br />CHECK if BILLING ADDRESS❑ <br />BP West Coast Products LLC <br />6747 Sierra ourt Suite <br />FACILITY NAME Arco 2133 <br />(925 <br />SITE ADDRESS 2908 <br />I <br />Benjamin Holt Drive <br />ZIP 94568 <br />Stockton <br />95207 <br />Street Number <br />Directiw <br />Street Name <br />$366.00 <br />citv <br />Zip Code <br />HOME or MAILING DRESS (If Different from Site Address) 4 <br />Centerpoint Drive <br />Street Number <br />Street Name <br />CITY La Pal <br />STATE Ca. ZIP 90623 <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />(530)621-0770 <br />PHONE #Z ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />ICONTR�U-, ' OR / SERVICE REOUESTOR <br />REQUESTOR <br />Randy Brow <br />CHECK if BILLING ADDRESS <br />.4 <br />BUSINESS NAME <br />Gettler-Ryan Inc. <br />PHONE # <br />925 <br />EXT. <br />551-7555 <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: f 0 � <br />FAX # <br />ATE: C2 �/ <br />6747 Sierra ourt Suite <br />(925 <br />)551-7888 <br />CITYDublin <br />STATE Ca <br />ZIP 94568 <br />BILLING ACKNOWLEDGEMENT: 1, the undersi ed property o usiness o �er,,acknowledge that all site and/or project specific ENvI? ENTAL HE TH DEPART ENJ <br />or activity will be billed to me or my business as identified this form. <br />I also certify that I have prepared this application and that the <br />COUNTY Ordinance Codes, Standards, STA'tmVITFEDERAL la <br />APPLICANT'S SIGNA <br />to be performed g4ll be done in <br />PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER ❑ OT R, <br />If APPLICANT is not the BILLING PARTY. proof of authoriZado <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, <br />above site address, hereby authorize the release of any and all results, <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAW <br />provided to me or my representative. <br />or authorized agent of same, <br />ges associated with this project <br />with all SAN JOAQUIN <br />DATE: April 1 2011 <br />AGENT ❑ Service anager <br />sign is r ired Title <br />the owner o erator of the roperty located at the <br />�ili;,chnical data or enviro ental/site assessment <br />NT s soon as it is a nd at the same time it is <br />TYPE OF SERVICE REQUESTED: Permit Approval <br />PAYMENT <br />FIEGEIVED <br />COMMENTS: <br />Replace faulty 91 fill spill bucket like for like. <br />APR 2 20�� <br />N JOAQUIN COUNTY <br />NVIRONMENTAL <br />Hr_ TH DEPARTMENT <br />ACCEPTED BY: !� u <br />EMPLOYEE #: f 0 � <br />ATE: C2 �/ <br />ASSIGNED TO: > <br />EMPLOYEE M , 6 3�, <br />AT ' �1 / <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />[1 b <br />P 1 E: <br />Fee Amount: $366.00 <br />Amount Paid <br />$366.00 <br />Payment Date April 1x, 2011 <br />Payment Type Credit Card 7 <br />Invoice # <br />Check # <br />Received By: <br />Confirmation # A53989 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />