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9255517888 Line 13:02:16 03-10-2014 3/17 <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 <br /> BP West Coast Products LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO 6080 <br /> SITEADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 Sierra Court,Suite G <br /> Street Number Street Name <br /> CITY STATE LP <br /> Dublin CA 94568 <br /> PHONE#1 Fx APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( l <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 /> 6805 Sierra Court,Suite G ( 925 ) 551-7888 <br /> CITY Dublin STATE CA Zip 94568 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 9e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE laws. y <br /> APPLICANT'S SIGNATURE: �i DATE: b 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT q 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, 1, 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. P <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT n- <br /> T <br /> AA <br /> D <br /> COMMENTS: <br /> Replace two black steel 90's and associated black steel nipples in product line in the diesel sump and trie"F /QAQ(Jl 014 <br /> tightening of black steel piping in the 91 turbine sump. ME,gC R01V N <br /> �EpAR 71' <br /> ENT <br /> ACCEPTED BY: l�it P,11-77 t-�2. — EMPLOYEE#: l/& - 0 DATE: <br /> ASSIGNED TO: �! EMPLOYEE#: -2� DATE: 3 ,2 <br /> Date Service Completed (if already completed): 44 1 SERVICE CODE: /Gr �' PIE: <br /> Fee Amount: =Amount Paid 3 7S,p-2) Payment Date 3� Ll <br /> Payment Type Ice# Check# Received By: <br /> ' <br /> EHD 48-02-025 1+�2✓0`i' SR FORM(Goiden Rod) <br /> REVISED 11/17/2003 <br /> Received Time Mar. 10, 2014 12: 53PM No- 5384 <br />