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9255517888 Line 11:05:45 10-03-2012 3/17 <br /> SAN JOAQUIN COUNTY FNVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION S 3C) <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 I Direction Street Name city Zip 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. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# ExT. <br /> 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 th ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED laws. <br /> APPLICANT'S SIGNATURE: DATE: 101311 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTIIER AUTHORIZED AGENT I Agent for Owner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required rate <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 A POSITION SENSITIVE SENSOR(P/N 794380-323) ON Diesel Fill Sump 1EGr-11VED <br /> OCT 0 3 2012 <br /> r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: q y PIE: <br /> Fee Amount: Amount Paid Payment Ante <br /> Payment Type , Invoice# Efre>rk-0-- Received By: <br /> tt Li Lf—IT <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Recelved Time Oct. 3. 2012 11 : 01AM No- 1284 <br />