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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH U>:PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station S260 <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Arco 6080 <br /> SITE ADDRESS 85 E Louise Avenue Lathrop 95330 <br /> Street Number Direction Street Name C ity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)4 Centerpoint Drive <br /> Street Number Street Name <br /> CITY La Palma STATE Ca. ZIP 90623 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (530 )621-0770 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Randy Brown CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# 6 t EXT. <br /> Gettler-Ryan Inc. 925-551-7555 <br /> HOME Or MAILING ADDRESS 6747 Sierra Court Suite J �AX# )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 /> 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, STAI� :FERAL laws. <br /> APPLICANT'S SIGNATURE, DArr: October 10, 2011 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN'A Service Manager <br /> lfAPPL/CANT is not the BILL/NG PARTY,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 environmentaUsite 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 /> PA <br /> TYPE OF SERVICE REQUESTED: Permit Approval MENT <br /> COMMENTS: OCT 11 2011 <br /> Replace fault sensor in vent sum SAN JOAQUN COUNTY <br /> p y p' ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Lowe EMPLOYEE#: q©ff DATE: l o !t 1/ <br /> ASSIGNED TO: /1/+-I ol-t EMPLOYEE#: :2--(a-�o DATE: l o/t 1711 <br /> Date Service Completed (if already completed): SERVICE CODE: 1 Q y P t E: a309 <br /> Fee Amount: $375.00 Amount Paid $375.00 Payment Date October 10,2011 <br /> Payment Type Credit Card Invoice# Check# Received By: f <br /> Confirmation #A61128 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />