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9255517888 Line 1 12•0•57 p.m. 03-04-2010 3/13 <br /> a71U1 JUHyU UU1\1 1 1i1V V 1RUINAlr 1\lilt,11GAJUIrl lit 11VIrIN L <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION C--7 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO 6080 <br /> SITE ADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 6747 Sierra Court,Suite J <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#") EXT. APN# LAND USE APPLICATION# <br /> { 925 ) 551-7555 <br /> PHONE#2 EXT. BOS DISTRICT -7LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESSD <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# EXT. <br /> 925 551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 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 tV the wok to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FE RAL <br /> 414-1 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUsrNESs OWNER❑ OPERA/TOR/ AGER ❑ OTHER AUTHORIZED AGENT Agent for 6wner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tilt e <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 JOAQUITI 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 /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: PA <br /> REPLACE A POSITION SENSITIVE SENSOR(P/N 794380-323)ON L8 RECENE� <br /> SAw JpAQUN'hITAL'Y <br /> .^J',-ri0 eu AFT�t ENT <br /> ACCEPTED BY: EMPLOYEE#: - �- DATE: Lqlio <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if aina4y completed): SERVICE CODE: r_ , P 1 E: ` <br /> Fee Amount: ` Amount Paid :3 ,A 5 Payment Date <br /> td <br /> Payment Type C Invoice# ehect* �, y 5 1 5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />