Laserfiche WebLink
9255517888 Line 1 0"'-26 p.m. 03-02-2010 3/16 <br /> 0AINJVAl1U VUIN1I r1NVIKV1N1V1E1NIALK]LrAL1113 XKIIVIVIINI <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# _ SERVICE REQUEST# <br /> SERVICE STATION fi-A � ��� 11:7v2Ci&J <br /> OWNER 1 OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ARCO 6080 <br /> SITE ADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court,Suite J <br /> Street Number Street Mame <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE 91 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAME GettlerR an Inc. PHONE# EXT. <br /> Ryan 925 551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 Sierra Court,Suite J ( 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 t t the York to b erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FE L S. <br /> APPLICANT'S SIGNATURE: DATE: 7i <br /> PROPERTY/BUSINESS OWNER❑ OPER. OR/MANAGER ❑ OTHER AUTHORIZED AGENT V 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 env ironmentaUsite 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. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT PA Ep <br /> COMMENTS: I MAR 0 2 2010 <br /> REPLACE VAPORLESS LEAK DETECTOR (VMI 99 LD-2000)ON 89 <br /> SAN"",QUtN cou"T <br /> EKOROHMEMIAL <br /> NFJLTH DEcARTbtENT <br /> ACCEPTED BY: 5-7 EMPLOYEE#: ` DATE. <br /> ASSIGNED TO: c EMPLOYEE#: DATE: <br /> Date Service Completed (if a dy completed): SERVICE CODE: t� P I E:' .3� <br /> Fee Amount: Amount Paid Payment Date 31 -2-11 -b <br /> Payment Type Ca Invoice# Check# i�\ S C1 4 b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />