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9255517888 Line 1 (1-1:41 p.m. 04-14-2009 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 ©2Fj <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO 6980 <br /> SITE ADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court,Suite J <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 <br /> PHONE#2 Ex T. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> Gettler Ryan Inc. 925 551-7555 <br /> HOME Or MAILING ADDRESS FAX# <br /> 6747 6747 Sierra Court,Suite J ( 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 t work to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FERE laws. <br /> APPLICANT'S SIGNATURE: t DATE: )00;i <br /> PROPERTY/BUSINESS OWNER❑ OPERATO / ANA OTHER AUTHORIZED AGENT Wf 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 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. N1 <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT GEt`J <br /> COMMENTS: tOQ� <br /> REPLACE A POSITION SENSITIVE SENSOR(P/N 794380-323)ON 89 FILL SUMP D�PR <br /> N JppC1VIMENTANZ <br /> p�Q�RSME <br /> ACCEPTED BY: EMPLOYEE#' DATE: <br /> ASSIGNED TO: EMPLOYEE Z DATE: <br /> Date Service Completed (if already completed/ SERVICE CODE: I E: <br /> Fee Amount: t!0 Amount Paid 3 `5 Paymen Date <br /> Payment Type C' Q Invoice# ehm "# S D U 3 Received By: <br /> Co h <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />