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9,255,517888 Line 1 <br />10:56:43 09-09-2013 7/12 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY 1V I SERVICE REQUEST # <br />Gasoline Station <br />P-ILLING ADDREss❑ <br />OWNER / OPERATOR <br />BP <br />West Coast Products LLC <br />cfrEcrc ttSltuNG AODWS <br />FACILITY NAME ARCO #5450 <br />925 551.7555 <br />SITEADDRESS 1617 <br />W <br />I <br />Freman4 <br />CITY Dublin <br />Stockton <br />95203 <br />5trast Number <br />Dlmc <br />city <br />Me COLO <br />HOME or MAILING ADDRESS (If Different from Ske Address) <br />3treat NumbsName <br />CITY <br />STATE 7jP <br />PHONE#t <br />(2W 462.1617 <br />APN# <br />3> <br />o LAND USEAPPLICATIpN <br />i l C> l <br />PHONE fit EXT. <br />BCS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SF,RVTVF, RF.nTT1FRTnR <br />RECUESTOR <br />CHECK If <br />Liddy McKenzie <br />P-ILLING ADDREss❑ <br />BUSINESS NAME <br />PHONE# ex►• <br />Gettler Ryan Inc. <br />925 551.7555 <br />How prMIauNGADDRESS 6747 Sierra Court, Suite J <br />FAxat (925)551.7888 <br />CITY Dublin <br />STATE CA ZIP 94668 <br />BILLING ACrKNOWLEDGEMIENT: 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 or <br />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 and FED AL laws. --- <br />APPLICANT'S SIGNATURE: DATE:Q'l*2013 <br />PROPERTY / BUSINESS OWNER E3 OPeRATDR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Project manager <br />ffAPPLlcAtTisnottheStcc wPAR proof ofauthorizadontosign fsrequired rifle PAYMENT <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the abov ECEIVED <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment info (� <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is prOVided to 0 9 2013 <br />my representative. <br />TYPE OF SERVICE REQUESTED; <br />.k <br />COMMENTS: t `' <br />Replace sensor on W41. sump L? 0-tiW-4- -�— �� �.� w5� C-2'pU7 t:.t,� <br />c w.rLV-s jwvu i4 <br />ACCEPTED BY: 4. EMPLOYEE #: DATE: <br />ASSIGNED TO: vV EMPLOYEE $: DATE: <br />Date Service Completed (H already completed): SERVICE CODE: PIE: ;?-3 0 <br />Fee Amount: �, Amount Paid Payment Date 0 <br />Payment Ty71111-3 <br />pe A4 fy Involce # Check # Received <br />-4- x44373..5 - <br />EHD 48-02-025 <br />07/17!08 <br />SR FORM (GoldP MENT' <br />EIVED <br />SEP 0 9 2013 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTh1ENT <br />