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SAN JOAQU RCOUNTY ENVIRONMENTAL HEAA nEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> Gas Station Arco 2093 ��a� 52 bd 6 391- <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Arco 2093 <br /> SITE ADDRESS 3425 Tracy Blvd Tracy 95376 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)4 Centerpoint Drive <br /> Street Number Street Name <br /> CITY La Palma STATE Ca. ZIP 90623 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (530)621-0770 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Randy Brown CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Gettler-Ryan Inc. (925)5_10-7 55 <br /> HOME or MAILING ADDRESS FAx# <br /> 6747 Sierra Court Suite J (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 to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: September 15, 2011 <br /> PROPERTY/BUSINESS OWNER❑ OPERAT AGER ❑ OTHER AUTHORIZED AGENT0--5ervice Manager <br /> IfAPPLiCANT 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: Permit Approval Us r- 4r7-4OA:r/T PAYMENT <br /> COMMENTS: <br /> SEP 16 2011 <br /> Replace faulty sensor in 91 Fill Sump. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HF�'.I-TH DEPARTMENT <br /> ACCEPTED BY: / pw EMPLOYEE M C�� DATE: g !& <br /> ASSIGNED TO: a� EMPLOYEE#: fr�6 DATE: 7// <br /> Date Service Completed (if already completed): SERVICE CODE: NIP PIE: �2 3c)8 <br /> Fee Amount: $375.00 1 <br /> Amount Paid $375.00 Payment Date September 15,2011 <br /> Payment Type Credit Card 7 Invoice# Check# Received By:G01�:7 <br /> Confirmation #A56523 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />