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19255517888 Main Fax � GETTLER RYAN INC 0:34 p.ln. 06-26-2007 3/10 <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 CHECKif 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 <br /> Street Name citv Zip gode <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 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESSIZI <br /> BUSINESS NAMEPHONE# 551-7555 Exr <br /> Gettler Ryan Inc. 925 <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 a t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and/ E AL laws. <br /> APPLICANT'S SIGNATURE: L DATE: " ) <br /> PROPERTY/BUSINESS OWNER[] OPERAT /M AGER ❑ OTHER AUTHORIZED AGENT 0 Agent for Owner <br /> If APPLICANT is not the BiLLINGPAR TY 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 it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT Y��lVE <br /> rf <br /> COMMENTS: <br /> REPLACE A POSITION SENSITIVE SENSOR(P/N 794380-323) V /�/� 'JL//V 2 6 203? <br /> (L! SAN ENVIgQUIN QU n <br /> HEALTH p N N rq <br /> ACCEPTED BY: �/`�11� L, EMPLOYEE M 26-7 c DATE: _ <br /> ASSIGNED TO: 1" EMPLOYEE#: O DATE: (2�_ <br /> Date Service Completed (if already completed): SERVICE CODE: j PIE: <br /> Fee Amount: 2 fj 6? Amount Paid Payment Date 1,, L(p O-7 <br /> Payment Type l Invoice# C # Received By: \v V <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />