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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION P iAQCv v' ') f911V9) <br /> jr <br /> OWNER/OPERATOR <br /> BP ARCO WEST COAST PRODUCTS LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO-7049 <br /> SITEADDRESS 800 E KETTLEMAN LANE LODI 95240 <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 /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK if BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONN25 551.7555 Exr <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: doze4 �— DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ga' A ent for Owner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required TitlePA <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the propertyAFieAr <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site a <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thelhTna time it i <br /> provided to the or my representative. LCC(( <br /> TYPE OF SERVICE REQUESTED: OVERFILL VALVE INSTALLATION ENV�AQ�INC <br /> COMMENTS: OEp Nrq( <br /> REMOVE EXISTING DROP TUBE IN MAIN REGULAR GASOLINE UST AND REPLACE WITH NEW OPW DROP TUBE WITH OVERFILL9�rMFN <br /> PROTECTION VALVE. <br /> ACCEPTED BY: t EMPLOYEE#: DATE: <br /> Gn � �p <br /> J <br /> ASSIGNED TO: EMPLOYEE#: Q � DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:44 1 '7& P 1 E: d � <br /> Fee Amount: Amount Pai [Li � Payment Date <br /> Payment Type C1 Invoice# Check# �S� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />