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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 OD6 00KI05I <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> BP ARCO WEST COAST PRODUCTS LLC <br /> FACILITY NAME ARCO -5450 <br /> SITE ADDRESS 1617 SFREMONT STOCKTON 95203 <br /> Street Number Direction Street Name City Zio 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 <br /> PHONE #2 ExT. BOS DISTRICT7LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK If BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONNE # 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 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 : <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 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 tir>��t is <br /> provided to me or my representative . I" YMe <br /> �� <br /> TYPE OF SERVICE REQUESTED : OVERFILL VALVE INSTALLATION to, `E 7cl <br /> COMMENTS : j <br /> REMOVE EXISTING DROP TUBES AND INSTALL NEW OPW-71 SO OVERFILL PROTECTION VALVES IN ALL USTS SqNjo 2019 <br /> FNtigQU/N <br /> HTN�FPgR 4Nry <br /> o MFNr <br /> ACCEPTED BY: 1 h EMPLOYEE #: `-7 Q DATE : <br /> ASSIGNED TO : f , � EMPLOYEE # : 4trvr32 DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : PIE : <br /> Fee Amount: 4L r Amount Paid Payment Date <br /> Payment Type Invoice # Check # `7� Received By : j , <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />