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9255517888 Line 1 01 '-):48 a.m. 10-27-2009 2/11 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 36, 12 -'s,id- o,is-&GS� <br /> OWNER 1 OPERATOR <br /> CHECK If BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACIuTY NAME ARCO 6020 <br /> SITE ADDRESS 1711 E YOSEMITE AVE MANTECA 95336 <br /> Street Number Dlr ation Street Name Ity Zi Cod <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#1 EXT• APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 2 d'k—3 i 0-- 1 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATI CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK If BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# EXT. <br /> Y 925 551-7555 <br /> HOME or MAILING ADDRESS FAx# <br /> 6747 Sierra Court,Suite J ( 925 ) 551-7888 <br /> CITY Dublin STATE CA Z1P 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 th the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED law i <br /> APPLICANT'S SIGNATURE: DATE: <br /> f t Z (0 <br /> PROPERTY/BOsINESs OWNER❑ OPERA /MANAGE OTHER AUTHORIZED AGENT QJ 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 it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT PAYMENJ <br /> COMMENTS: E I V E D <br /> REPLACE POSITION SENSITIVE SENSOR(PART NO 794380-323)ON 87 FILL SUMP OCT 2 7 2000 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEIN T <br /> ACCEPTED BY: ©L-i v t IL EMPLOYEE#: U Tj L DATE: [ Z ei <br /> ASSIGNED TO: l IJ L-- 1 EMPLOYEE M )—&-7 0 DATE: i -L> &e <br /> Date Service Completed (if already completed): SERVICE CODE: g P 1 E: 3 <br /> Fee Amount: 3 LAS L,-1) Amount Paid 3 � 5 Payment Date �) I-?.I O <br /> Payment Type CQ Invoice# colt# Ll D 2 b Received By: , <br /> • Co�n �' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />