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925 517888 Line 6:43 09-09-2013 7/12- <br />SERVICE <br />"PEGUEST <br />Type of Business or Property <br />lf8rLuNaADcREss13 <br />FACILITY !n # <br />SERVICE REQUEST # <br />Gasoline Station <br />925 551.7555 E><r. <br />How orMAILINGADDRESS 6747 Sierra Court, Suite J <br />OWNER I OPERATOR <br />FAX# 551.7888 <br />1526) <br />BP West Coast Products LLC <br />CHECKtfBILLINOADDRES3 <br />FAmm NAME ARCO #5450 <br />SITEADDREss 1617 <br />WI <br />Fremonb <br />Stockton 55203 <br />5tneathmumWr <br />OSredNon <br />Street are <br />m 210 Coda <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Stream NumberF Leet Name <br />CITY <br />$TATE Zip <br />PHONE#1 EM T <br />061, 462.1617 <br />PN# <br />LAND APPLJCATION41 <br />PHONE #2 Exr' <br />BOS DMMCT <br />LOCATION CODE <br />REcwESTOR <br />lf8rLuNaADcREss13 <br />Liddy McKenzie <br />REss <br />BtrSWESS NAME <br />GettEer Ryan Inc. <br />925 551.7555 E><r. <br />How orMAILINGADDRESS 6747 Sierra Court, Suite J <br />FAX# 551.7888 <br />1526) <br />CtrY Dublin <br />STATE CA ZIP 94568 <br />MILLING ACKNOWLEDGE ENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />admoMedge that all site andler project spelt ENvIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FED AL laws. - <br />APPLICANT'S SIGNATURE: � �-�%�'" � DATE:1?74 '2013 <br />PROPERTY I BUSINESS OWNER E3 0PERATORIMANACER ❑ OTHERAt1TNoRaEDAGENr EProject manager <br />tfAFFuc.AN+risnot the BiwNGPARTY Proof ofauthorizationtosign isrequired . Title fJECEI NT <br />AUTHORIZATION TO RELEASE INFORINATION: When applicable, 1, the owner or operator of the property located at the ab <br />aveECEi�ED <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment soinfe 0�y <br />to the SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a$ on as it is available and at the same time it is provided t0 2013 <br />my representative. ,¢ <br />TYPE OF SERVICE REQUESTED; <br />Replace sensor an ., sump L?C <br />ACCEPTED By., " , EMPLOYEE #: DATE: i <br />ASSIGNED To: S EMPLOYEE #: DATE: <br />Date service Completed (if already Completed): sERYiCE CODE. -PIE: <br />Fee Amount -75 Amount Paid Payment Date <br />Payment Type Pp Invoice N Check I Received By: <br />1 <br />EHD 48.02-025 <br />07117M <br />SR FORM (GoldP MENT <br />EiVED <br />6 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />