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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # GAS STATION OWNER i OPERATOR CHECK If BILLING ADDRESS ❑ BP ARCO WEST COAST PRODUCTS LLC FACILITY NAME ARCO SS 6080 SITE ADDRESS 85 E LOUISE AVENUE LATHROP 95330 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT, SUITE G Street Number Street Name CITY STATE ZIP DUBLIN CA 94568 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 925 ) 551 -7555 PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR TRAVIS BOWEN CHECK if BILLING ADDRESS BUSINESS NAMEPHONE # EXT . GETTLER-RYAN , INC . 925 551 -7555 HOME or MAILING ADDRESS FAX # 6805 SIERRA COURT, SUITE G ( 925 ) 551 -7888 CITY DUBLIN STATE CA ZIP 94568 BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator Or authorized age acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated witl 1 1 A p)/ ;` or activity will be billed to me or my business as identified on this form . //��,,JJ,,�� CA6 I also certify that I have prepared this application and that the work to be performed will be done in accordance with all S'A 9Q?3 /8/2024 U` �T//T��//LL��99 COUNTY Ordinance Codes, Standards , STATE and FEDERAL laws . SAN JOA C �l HFq NV/ O APPLICANT ' S SIGNATURE : 7'L�'-� S �&u')W DATE ; LTh NME UNTy A � PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 1;r Agent for Owner T MFNT If.4PPL/CANT is not the BILLING PARTY proof of authorization to sign is requited Title AUTHORIZATION TO RELEASE INFORMATION : When applicable, I , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative . TYPE OF SERVICE REQUESTED : U S T l� COMMENTS : REPLAING THE DAMAGED DROP TUBE ON THE 87 GRADE UST LIKE FOR LIKE . THE MODEL WILL BE THE OPW- 71 SO . ACCEPTED BY : CS f—fi EMPLOYEE # : DATE : ASSIGNED TO : ( L �� v EMPLOYEE # : DATE : Z `I Date Service Completed ( If already completed ) : — SERVICE CODE : : 2qa . PIE : 2� �� Fee Amount: LIS � '� Amount Paid LIES � . db Payment Date 2 Payment Type - Invoice # Check # f 7 S I l S �( Receive By : EHD 48-02-025 17 g T S o I ' SR FORM (Golden Rod) REVISED 11 /17/2003