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SAN JOAQUIN Ir )UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION ct7, i <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ARCO-6080 <br /> SITE ADDRESS 85 E LOUISE LATHROP <br /> Street Number I 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 21418 020 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAMEGettler Ryan Inc. ( EXT. <br /> 551-7555 <br /> HOME or MAILING ADDRESS FAx# <br /> 6805 Sierra Court, Suite G ( 925) 551-7888 <br /> CIN 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 ENVIRONMEN-rAi. 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 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 /> � /e <br /> APPLICANT'S SIGNATURE: K �i 11�1116z__ DATE:01/07/2016 <br /> PROPERTY/Bt SINESS ON\'NER❑ OPERATOR/MAN'AGE:R ❑ OTIIER At'THORILED AGENT C;' Agent for Owner <br /> it APPL1C.IAT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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: Replacement ST e <br /> COMMENTS: PAYMENT <br /> REPLACE INTERSTITIAL SPACE SENSOR, PART NUMBER 794380-303 IN EXISTING TANKS. RECEIVED <br /> JAN 112016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTA <br /> �n LT PARTMEN <br /> ACCEPTED BY: I EMPLOYEE#: DA ,/ ,p <br /> ASSIGNED TO: L t EMPLOYEE#: DATE: /,// ,/�o <br /> Date Service Completed (if already Completed): SERVICE CODE: ���, P/E:�) < <br /> Fee Amount: Amount Paid ob Payment Date t tt I tP !J <br /> Payment Type Cf�S Invoice# Check# 3 w Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />