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9455517888 Line 12:42:08 02-06-2015 3/12 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 31,3 <br /> OWNER t OPERATOR <br /> BP West Coast Products LLC CHECKif BILLING ADDRESS <br /> FACILITY NAME ARCO 6080 <br /> SITE ADDRESS85 E LOUISE AVE LATHROP95330 <br /> Street Number Direction Street Name Ci 2 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 Exr. APN At y LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 Ext BOS DISTRICT , LOCATI CODE <br /> ( ) > () ' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE CHECK ifBILLING ADDRESS <br /> © <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# ExT. <br /> 925 551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 6805 Sierra Court,Suite G ( 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 the work to be formed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERA WS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/111ANAG OTHER AUTHORIZED AGENT Agent for Owner <br /> If APPLICANT 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 itN <br /> provided to me or my representative. RF NFNT <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: 4V,b <br /> REPLACE A POSITION SENSITIVE SENSOR(P/N 794380-323) FOR ALL SITE UDC'S TO 2794380-208 "'-4z N04 4a FCOU J <br /> SENSORS AND REPLACE"LIKE FOR LIKE"ANNULAR SPACE SENSOR 794380-303 IN ALL 3 TANKS. sp <br /> ACCEPTED BY: t° u�` EMPLOYEE M DATE: <br /> ASSIGNED TO: -"V- EMPLOYEE M DATE: <br /> Date Service Completed (if already co pleted): SERVICE CODE: i PIE: <br /> Fee Amount: .3 q o "- Amount Pa 3�( vd Payment Date S— <br /> Payment Type K Invoice# C # b2 Received W771 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Received Time Feb. 6. 2015 11 : 31AM No. 8055 <br />