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•%,u4"lil V Liu <br /> SAN .IOA(,�,N COUNTY ENVIRONMENTAL HEAL.., DEPARTMENT MAR 2 2 2018 <br /> SERVICE REQUEST ENv11Z0NNIENTAL HEALTH- <br /> Type of Business or Property FACILITY ID# SERVICER VW I ,NI I'-1 A' <br /> SERVICE STATION <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO 6080 <br /> SITE ADDRESS 85 E LOUISE FLATHROP 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 1 (-I L{, �-7 L: <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( CU3 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE CHECK if BILLINGADDRESSI] <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: 1, 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('odes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �� �� DATE: f' Z/ /pp <br /> PROPERTY/BusiNESS ONN NER❑ OPERA"rOR/INIANAGER ❑ OTHER;kt"FFIORIZED;kGEN'r V Agent f6 Owner <br /> /'APPLICANT is not the BILLING PART,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located�f <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asgg'��.11 <br /> information to the SAN JOAQUIN COUN'T'Y ENV IRON MENTAI.HEAL I-H DEPAR"rMENT as soon as it is available and at the same tlm w ,V <br /> provided to me or my representative. i d �® <br /> TYPE OF SERVICE REQUESTED: REPLACE ONE VACUUM SENSOR SAN✓ ? 2018 <br /> COMMENTS: N�4 /RC /�(' <br /> REPLACE ONE VEEDOR ROOT VACUUM SENSOR FOR 91 PRODUCT LINE SECONDARY CONTAINMEP �N �Nry <br /> ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: n�Q <br /> ASSIGNED TO: EMPLOYEE#: DATE: .3 ,I <br /> Date Service Completed (if ready completed): SERVICE CODE: ( � PIE: (l� Og <br /> Fee Amount: Amount Paid A,C7/;.Dz> Payment Date <br /> Payment Type e Invoice# Check# �Lqr Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />