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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#` <br /> i; <br /> SERVICE STATIONLo DE-3 <br /> OWNER/OPERATOR r <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS❑ <br /> FAGLnT NAME ARCO 6080 <br /> SITE ADDRESS 85 E LOUISE LATHROP 95330 <br /> Straet 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 I street Name <br /> CITY STATE ZIP <br /> DUBLIN CA 94568 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 925 ) 551.7555 I �'��O I O <br /> PHONE#2 Exr• SOS DIS <br /> ( ) V21�'T LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE <br /> CHECK if BILLING ADORE <br /> BUSINESS NAMEPHONE# EXT. <br /> Gettler 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 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: 3���`�--- DATE:- <br /> PROPERTY/ <br /> ATE:PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 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 locate the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same i ,t �� <br /> provided to me or my representative. fit► <br /> TYPE OF SERVICE REQUESTED: REPLACE ONE VACUUM SENSOR 4 y� <br /> COMMENTS: <br /> REPLACE ONE VEEDOR ROOT VACUUM SENSOR FOR 91 PRODUCT LINE SECONDARY CONTA N °FH, <br /> FHT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: �ApEMPLOYEE#: DATE: r7` , f b <br /> Date Service Completed (if already completed): SERVICE CODE: p/ P t E: y ;! <br /> Fee Amount: Amount Pairy /fSt_ D Payment Date U <br /> Payment Type Invoice# Check# (z`F -i 777Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />