COMPLIANCE INFO_2004 - 2007 - Laserfiche WebLink

Home Browse Search

J19255517888 Main Fax GETTLER RYAN INC 2:32 p.m. 10-16-2007 3/10 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# SERVICE STATION =5S ��Qny2321 OWNER 1 OPERATOR CHECK if BILLING ADDRESS BP West Coast Products LLC FACILITY NAME ARCO 6080 SITE ADDRESS 85 TE LOUISE AVE LATHROP 95330 Street Number Street Name C ity Zip HOME Or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court,Suite J Street Number Street Nam CRY STATE LP Dublin CA 94568 PHONE#1 EXT. APN# LAND USE APPLICATION# { 925 ) 551-7555j t PHONE#2 ExT BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR LIDDY MCKENZIE CHECKIfBILLINGADDRESSIZI BUSINESS NAMEPHONE# Exr' Gettler Ryan Inc. 925 551-7555 HOME or MAILING ADDRESS FAX# 6747 6747 Sierra Court,Suite J ( 925 ) 551-7888 CITY Dublin STATE CA ZIP 94568 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the wo to be pe ed will be done in accordance with ail SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laWf- APPLICANT'S SIGNATURE: DATE: le //4./, O'7 PROPERTY/BUsINESS OWNER❑ OPERATOR/MA R �-�;hlo�,<izftion ER AUTHORIZED AGENT 1Z Agent fo Owner If APPLICANT is not the BILLING PAR ,proof to sigh is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, 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�C,jSa,(t1e time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: UST RETROFIT , �� COMMENTS: 1 8 REPLACE A POSITION SENSITIVE SENSOR (P/N 794380-323)IN THE 89 STP SUMP 8'q/V,/04Q0//V 'qN✓p 2��J (north side closet to the building) NTN p pgEN rY HT,yENT EMPLOYEE M �' ?,_ ACCEPTED BY: L`L i l E [ 19.� Z_� DATE: e` ASSIGNED TO: 4,t o t-C EMPLOYEE M '�2_(,;-7 r DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: 2- Fee jFee Amount: 'A �I-i -I , Amount Paid oo Payment Date v) vq 0 Payment Type �,P Invoice# Check# Received By: ill k—j EHD 48-02-025 9 ~ SR FORM(Golden Rod) REVISED 11/17/2003