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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST IeZ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION ? <br /> OWNER/OPERATOR `7 <br /> BP West Coast Products LLC CHECK if BIL LING ADDRESS❑ <br /> FACILITY NAME ARCO 6080 <br /> SITEADDRESS 85 E LOUISE LATHROP 95330 <br /> Stroet Number I Dirac .. Street Name cily 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 I(/) l a-70) <br /> O <br /> PHONE#2 ExT• 'FF'' BOS DIS <br /> T�Itr <br /> ( ) T LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE <br /> CHECK if BILLING ADDRE <br /> BUSINESS NAMEGPHONE# ExT• <br /> ettler 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./�� " <br /> DATE• <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT V Agent for Owner <br /> IfAPPLICANT 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 same491.1'r <br /> provided to me or my representative. r <br /> VA6 <br /> TYPE OF SERVICE REQUESTED: REPLACE ONE VACUUM SENSOR jD <br /> COMMENTS: <br /> REPLACE ONE VEEDOR ROOT VACUUM SENSOR FOR 91 PRODUCT LINE SECONDARY CONTAIN q�N , <br /> FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: _YAcG <br /> ASSIGNED TO: EMPLOYEE M DATE: r() <br /> Date Service Completed (if already completed): SERVICE CODE: C� PIE: y S! <br /> Fee Amount: Amount Pai /_ D Payment/Date U <br /> Payment Type �L Invoice# Check# (2`� Recei d By: <br /> all— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />