Laserfiche WebLink
9255517888 Line 1 08:3 : 1 a.m. 07-21-2016 3/17 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type"of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION C- ;T�5 � <br /> OWNER/OPERATOR CHJ CK If BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO 5450 <br /> SITE ADDRESS I I ( r I►'I U-� `::a STOCKTON <br /> Street Number Direction treat Name Nw Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 6805 Sierra Court,Suite G <br /> Street Number Street NAMO <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE CHECK If BILLINGADDRESS13 <br /> BUSINE98 NAME Gettler Ryan Inc. PHONE# Ex' <br /> 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 to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �` DATE: 0 -20., <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Qr Agent for Owner <br /> If APPLICANT is not the BILLING PARm proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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. qY <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT RFW' <br /> ✓v Fl <br /> COMMENTS: /// <br /> PENETRATION FITTING REPLACEMENT AND SB989 RETEST OF 87 MAIN STP SUMP,87 MANIFOLDED STP SUMP,91 Sq �pqQ PI ZQj <br /> FILL SUMP,UDCU/N <br /> 3/4 AND UDC 7/8. ThDF q9T q, NTj <br /> _ FHT <br /> ACCEPTED BY: t EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: ` <br /> -.r z1 7- 1- <br /> Date Service Completed (if already completed): SERVICE CODE: CIS PIE: C;; <br /> Fee Amount: c� `"I Amount Pald D _ Payment Date —71:74_I <br /> 1 jo <br /> Payment Type C4j�-CAA Invoice# Check# A Received By: t� <br /> EHD 48.02-025 SR FOR6tGdi1 % <br /> REVISED 11/17/2003 <br /> JUL 21 2016 <br />