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,517888 Line 11:00:53 03-20-2013 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 p0 &e�96� <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 ZipCode <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 <br /> PHONE#2 EXT• BOS DISTRICT LO CATION CODE <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 /> 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 that thKaw,.ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FE DE <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE /MAN OTHER AUTHORIZED AGENT� Agent for wner <br /> I.fAPPLICANT is not the BILLING PARTY,600fof 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 <br /> COMMENTS: <br /> Replace flex hose and steel piping in the diesel turbine sump <br /> 1 <br /> ACCEPTED BY: W(Nelr� EMPLOYEE#: `Z O 5 DATE. 2j ��j /3 <br /> ASSIGNED TO: EMPLOYEE#: G DATE: 'j/Zp/(3 <br /> Date Service Com��p�pleted (if already completed): SERVICE CODE: 0cP I E: a 7j p g <br /> Fee Amount: 3 7S Amount Paid — _ Payment Date 3 3 <br /> Payment Type nInvoice# A Check# Received By: <br /> EHD 48-02-025 C, ! i `Q SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Received Time Ma r. 20.t213't10'*:"54AM No. 2602 <br />