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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> SERVICE STATION ocoo3bob C) 6 796 ; <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS ❑ <br /> BP ARCO WEST COAST PRODUCTS LLC <br /> FACILITY NAME ARCO -5450 <br /> SITE ADDRESS 1617 S FREMONT STOCKTON 95203 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT, SUITE G <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> DUBLIN CA 94568 <br /> PHONE #1 EXT. APN # / LAND USE APPLICATION # <br /> ( 925 ) 551 . 7555 / 3 C Ho <br /> PHONE #2 ExT. BOS DISTRICTION CODE <br /> ( ) cc, I LOCATv o <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK if BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONE # 551 . 7555 EXT , <br /> 925 <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 thip work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FERE laws . <br /> APPLICANT ' S SIGNATURE : DATE ; <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Ex Agent for Owner <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required T � a <br /> M ll <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, I, the owner or operator of the propel 4,,s/he <br /> above site address , hereby authorize the release of any and all results, geotechnical data and/or environm Ite asse t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at e sit t4 it is <br /> provided to me or my representative . SAN <br /> TYPE OF SERVICE REQUESTED : OVERFILL VALVE INSTALLATION HEALTH ONMFN"Nn. <br /> COMMENTS : JlNrMEN. <br /> REMOVE EXISTING DROP TUBES AND VENT BALL FLOAT CAGES AND INSTALL NEW OPW-71 SO OVERFILL PROTECTION VALVES IN <br /> ALL USTS <br /> ACCEPTED BY: �i t EMPLOYEE # : DATE : 1 , V / <br /> ASSIGNED TO : `t ` ! EMPLOYEE # : DATE : �1 ✓/ /� / <br /> aa <br /> Date Service Completed ( if already completed) : SERVICE CODE : ` C- PIE : d309 <br /> Fee Amount : Amount Pal&:# (� v v Payment Date <br /> Payment Type Invoice # Check # 141 Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />