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9255517888 Line 1 0120 p.m. 03-28-2016 3/10 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION A—D--; <br /> OWNER I OPERATOR <br /> BP West Coast Products LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO 5450 <br /> SITEADDRESS 1617 W FREMONT STOCKTON 95206 <br /> Street Number I Direct'on Street Name city ZipCode <br /> HOME or MAILING ADDRESS (if Different from Site Address) 6805 Sierra Court,Suite G <br /> Street Number tr t Name <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE CHECK If BILLINGADDRESS121 <br /> BUSINESS NAMEPHONE# EXT. <br /> Gettier Ryan Inc. 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 ACKNQWLEDGEMENT: 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 wo O be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL . <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERD OR/MANAGER L] OTHER AUTHORIZED AGENT q Agent for Owner <br /> If APPLICANT is not t e 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 OFSERVICE REQUESTED: USTRETROFIT PAYMENT <br /> COMMENTS: <br /> REPLACE ONE DAMAGED SUMP LID AND RING"LIKE FOR LIKE" MAR 2 8 20116 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMFNTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 13A EMPLOYEE M DATE: 'j 16 <br /> ASSIGNED TO: /2-1 EMPLOYEE M DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: P/ <br /> Fee Amount: _,MO.()o Amount Paid -,3 C C) C- Payment Date u 3 <br /> Payment Type C_ Invoice# Gheek# ASLi Received By: <br /> r' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />