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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 <br /> OWNER/OPERATOR <br /> BP ARCO WEST COAST PRODUCTS LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ARCO-7049 <br /> SITE ADDRESS 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#I ExT• APN# LAND USE APPLICATION# <br /> ( 925 ) 551.7555 <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK if BILLING ADDRESS <br /> BUSINESS NAME Gentler Ryan Inc. PHONE925# 551.7555 E> <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: 1/% �� DATE: <br /> hi Oe / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT yo A entfor Owner <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title PA /�,�� <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property �7 9lSREN70 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site a O <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at theft tii a it i <br /> provided to me or my representative. '�'`C�((., <ZA 8 <br /> TYPE OF SERVICE REQUESTED: OVERFILL VALVE INSTALLATION E ApUIyC <br /> COMMENTS: OFP N� ir <br /> REMOVE EXISTING DROP TUBE IN MAIN REGULAR GASOLINE UST AND REPLACE WITH NEW OPW DROP TUBE WITH OVERFILL <br /> PROTECTION VALVE. <br /> O <br /> ACCEPTED BY: t ^� EMPLOYEE M Q DATE: to <br /> l <br /> ASSIGNEDTO: EMPLOYEE DATE: /:_ /p <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: d9-vi <br /> Fee Amount: Amount Pai LJ-C-1 Payment Date k!� <br /> Payment Type C Invoice# / Check# /S3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />