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9255517888 Line 12:42:36 12-17-2012 3/13 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 6 662 <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECKIfBILLINOADDRESSO <br /> FACILITY NAME ARCO 6080 <br /> SITE ADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number Direction Street Name city ZiD Code <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. API# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK it BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONE#925 551-7555 EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 Sierra Court,Suite J 1 925 ) 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 Ije work c performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FED LL lax <br /> APPLICANT'S SIGNATURE: DATE: ' I Z— <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IAgent 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 theme time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: <br /> rr •Vo V <br /> Replace sensor S 12. A vacuum sensor for the vent secondary, located In the 87 turbine surr �4 < <br /> •�OHO <br /> �q tiT U <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: ` Amount Paid — B O Payment Date <br /> Payment Type /J Invoice# Check <br /> # Received y; <br /> EHD 48-02-025 C1 (g�(Q SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Received Time Dec. 17, 2012 11 : 37AM No. 1880 <br />