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19255517888 Line 1 ',3:03:08 07-15-2013 3/12 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# SERVICE STATION 3(o 3s— S o o (0 r� 7 OWNER/OPERATOR / BP West Coast Products LLC CHECK if BILLING ADDRESS FACILITY NAME ARCO 6080 SITE ADDRESS 85 E LOUISE AVE LATHROP95330 Street Number Direction Street Name Ci ZI Code HOME or MAILING ADDRESS (if Different from Site Address) 6747 Sierra Court,Suite J Street Number Street Name CITY STATE ZIP Dublin CA 94568 PHONE#1 EXT. APN# / J Ci LAND USE APPLICATION# ( 925) 551-7555 1 C 0 -7 V I PHONE#2 ExT• BOS DISTRICT ..7 LOCtJIO CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS BUSINESS NAME Gettler Ryan Inc. PHONE# 551-7555 EXT 92 HOME or MAILING ADDRESS FAX# 6747 Sierra Court, Suite J ( 925) 551-7888 CITY Dublin STATE CA ZIP 94568 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDF_ aws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT W Agent for Owner If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: UST RETROFIT RECE IVEn COMMENTS: JUL r E 2013 r J REPLACE A POSITION SENSITIVE SENSOR(P/N 794380-323)on vent sump SAN JOAQUIN COUNTY ENVIRONMENT HEALTH DEPARTMENT ACCEPTED BY: P?.T Z EMPLOYEE M DATE: -7 I ASSIGNED TO: r i \� N EMPLOYEE M DATE: 7 / I Date Service Completed (if already completed): SERVICE CODE: PIE: ��v Fee Amount: 7J -j Amount Paid 375 p Payment Date Payment Type (M. voice# Check Received By: EHD 48-02-025 p, 4 I J, SR FORM(Golden Rod) REVISED 11/17/2003 Received Time Jul. 15. 2013 12 :56PM No. 3591