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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REM IFST # <br /> SERVICE STATION r/4 o eo a (02 SAO X51 ; <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> BP ARCO WEST COAST PRODUCTS LLC <br /> FACILITY NAME ARCO SS 2093 <br /> SITE ADDRESS 3425 N TRACY BLVD TRACY 95376 <br /> Street Number Direction 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 # PBOS <br /> SE APPLICATION # <br /> ( 925 ) 551 -7555 <br /> PHONE #2 ExT ISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK if BILLING ADDRESS <br /> BUSINESS NAME GETTLER-RYAN , INC . PHONE # ExT. <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 : /�'/ � f— DATE : `7/ / � '?�Z <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT la' 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 time it is <br /> provided to me or my representative. S y 16, f7�D ' p <br /> TYPE OF SERVICE REQUESTED : ` IC NT <br /> COMMENTS : <br /> AREPLACE EXISTING FILL MANWAYS AND BUCKETS WITH NEW MANWAYS , BUCKETS , LIR IN LL /1�N 2 <br /> REPLACE EXISTING OVERFILL VALVES/DROP TUBES WITH NEW OPW 71 SO SOA <br /> AT D p RNTCA�A/ <br /> TMENT <br /> ACCEPTED BY : J fa / `Q v n/ EMPLOYEE # : DATE : 1' 22 <br /> ASSIGNED TO : L ,.g ^ � EMPLOYEE # : DATE : 8 . 2 <br /> Date Service Completed ( if already completed) : SERVICE CODE : rq , ,dZe7g PIEZE30 <br /> Fee Amount : `T o O Amount Paid C Payment Date �l ZZ <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />