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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GASOLINE STATION 3 W j5 __ 4 Od liI '2-Lk5' <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITYNAME ARCO #6080 <br /> SITE ADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 SIERRA CT. <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 /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLINGADDRESSM <br /> BUSINESS NAME PHONE# EXT. <br /> Gettler Ryan Inc. 925 551-7555 15 <br /> HOME Or MAILING ADDRESS FAX# <br /> 6747 SIERRA CT. (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 I have prepared this application and t t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F // 7 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE R/ T.MANAGER ❑ OTHER AUTHORIZED AGENCp{`uAthe-T o <br /> 9-1. <br /> n <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titter <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmental/site 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 REMOVAL <br /> 94 <br /> COMMENTS: RECE�V D <br /> UST REMOVAL-Remove(3)12,000 gallon Underground Storage Tanks r1G\.,rC <br /> Remove 4 dispensers and islands. OCT 14 2010 <br /> SAN JOAQUIN COUNTY <br /> EWRONMEHEALTH D PARTu L <br /> HEALTH <br /> krr <br /> ACCEPTED BY: O Li UE I V A EMPLOYEE#: Ox Z ; DATE: !'T1 L ( 0 <br /> ASSIGNED TO: EMOPLOYEE#: ��t/b DATE: 11), <br /> U <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P/E! 23 0 <br /> Fee Amount.-f �--� Amount Paid ' D t 6D Payment Date l� 0 <br /> Payment Type Invoice# Check# ���— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />