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SAN JOAQUIr, BOUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 'S&OT(J0nN <br /> OWNER/OPERATOR <br /> BP ARCO WEST COAST PRODUCTS LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO-6080 <br /> SITE ADDRESS 85 E LOUISE A LATHROP 95330 <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# LAND USE APPLICATION# <br /> ( 925 ) 551.7555 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <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 /> 1 also certify that 1 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 law ! 1-5APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE /MANAGER ❑ OTHER AUTHORIZED AGENT W Agent for Owner <br /> If APPLICANT is not the BILLING PA RTI-,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the pr��tftkylhe <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/';i ZV�ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andlk eiame time It Is <br /> provided to me or my representative. 44-1-0�'`[p 3 <br /> TYPE of SERVICE REQUESTED: OVERFILL VALVE INSTALLATION eml7ln— -n <br /> COMMENTS: �ERARTMFN <br /> REMOVE EXISTING DROP TUBES AND VENT BALL FLOAT CAGES AND INSTALL NEW OPW-71 SO OVERFILL PROTECTION VALVES TN <br /> ALL USTS <br /> ACCEPTED BY: -ZO EMPLOYEE#: DATE: <br /> ASSIGNED TO: Wv` EMPLOYEE#: DATE: ✓� �C�� <br /> Date Service Completed (if already completed): SERVICE CODE: ( P/E: <br /> Fee Amount: Amount Pai � D� Payment Date <br /> Payment Type Invoice# Check# /�7Vr Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />