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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST JAN 2 2 2018 <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 /> FACILIIYNAME ARCO.7049 <br /> SITE ADDRESS 800 EKETTLEMAN LANE LODI 95240 <br /> Stmt Number Olnetlon 1mt N.m. CIly Zip Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT,SUITE G <br /> Stmt Number SIIW Nem. <br /> CITY STATE ZIP <br /> DUBLIN CA 94568 <br /> PHONE#1 Ems- APN# LAND USE APPLICATION# <br /> ( 925 ) 551.7555 <br /> PHONE#2 En. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK If BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONE En- <br /> 945 551.7555 <br /> HOME or MAILING ADDRESS FAXII <br /> 6805 SIERRA COURT,SURE G ( 925 ) 551.7888 <br /> CITY DUBLIN STATE CA ZIP 94568 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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: �jr �j �� DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/IIIANAGER ❑ OTHERAUTHORIZEDAGEN-rQ A�rOwner <br /> /fAPPLICdNT is not the BILLING PART) proof of authorization to sign is required Title <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.lsite 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: FFS OVERFILL VALVE INSTALLATION <br /> COMMENTS: <br /> REMOVE EXISTING DROP TUBE IN MAIN REGULAR GASOLINE UST AND REPLACE WITH NEW DROP TUBE WITH FPS DEFENDER <br /> SERIES OVERFILL PROTECTION VALVE <br /> O <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (U already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />