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9255517888 Line 1 12:24:25 p.m. 12-08-2008 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 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO 6080 <br /> SITE ADDRESS BS E LOUISE AVE LATHROP 95330 <br /> Street Numbs Dimcliona e chy Z10 Code, <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court,Sults J <br /> Street Number <br /> CITY STATE LP <br /> Dublin CA 94568 <br /> PHONE 91 Err. APN aM LAND 113E APPLICATION 9 <br /> ( 925 ) 551-7555 S <br /> PHONE#2 Exr• BOS DISTRICT y LOCATIOH CODE f <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK If BILLING ADDREss <br /> BUSINESS NAME Gettlw Ryan Inc. PHONE 925 551-7555 Exr. <br /> HOME or MAjuNG ADDRESS FAX$ <br /> 6747 6747 Sierra Court,Sults 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 the work to be performed will be done in accordance with all SAN JOAQUna <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTnmAUTHORIZBDAGENT If AgentforOwner <br /> If APPLIC4NT is nor the B/LL/NG 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 saw 1l it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT Q,E <br /> COMMENTS: <br /> REPLACE A POSITION SENSITIVE SENSOR(P/N 794380-323)ON PIPING SUMPIN <br /> L8 bPN 30f,00 MENTA <br /> EN\Jk pk pATM NN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 2 DATE: <br /> Date Service Completed (If already comple SERVICE CODE: P 1 E: <br /> Fee Amount: I'S Amount Paid 3} U Payment Date Z g` <br /> Payment Type I L Invoice# Check Received By: <br /> EHD 48-02025 v36 �Z� -Z, � T-1 Ic�l1 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />