Laserfiche WebLink
9255517888 Line 48:04 06-04-2012 3/13 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION7:�-Acri v <br /> OWNER 1 OPERATOR <br /> BP West Coast Products LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ARCO 6080 <br /> SITEADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court,Suite J <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 EM• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE <br /> CHECK If BILLING ADDRESS10 <br /> BUSINESS NAME Gettler Ryan Inc. PHONE d 551-7 5 Exr <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 Sierra Court,Suite J 1 925) 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 th ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE aws. J <br /> APPLICANT'S SIGNATURE: DATE:! <br /> PROPERTY/BUSINESS OWNER❑ OPE /MANAGER OTHERAUTHORIzED AGENT 1Z Agent for Owner <br /> If APPLICANT is not the B1L ING 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: UST RETROFIT RECEIVED <br /> COMMENTS: TUN - 4 2w <br /> Replacing the Veeder-Root Pressure Line Leak Detector(PLLD) .J <br /> SAN JOAQUIN COUNTY <br /> ENViRONENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7/ <br /> ASSIGNED TO: r-IP v EMPLOYEE#: DATE: ! <br /> Date Service Completed (if already completed): SERVICE CODE: Lq P.t E:--) Q <br /> Fee Amount: "' Amount Paid "C37 S`— Payment Date �l (( -2— <br /> Payment <br /> ( -Z_Payment Type l , Invoice# Check# Received By:- f <br /> �L <br /> EHD 48-02-025 -7S-7T SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />