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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station 54 ova Vj-3e) <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESSO <br /> FACILITY NAME Arco 6080 <br /> SITE ADDRESS 85 E Louise Avenue Lathrop F95330 <br /> Street Number Direction Street Name City i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)4 Centerpoint Drive <br /> Street Number Street Name <br /> CITY La Palma STATE Ca. ZIP 90623 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (530 )621-0770 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Randy Brown CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# 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: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENIAL 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST ' nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: January 23, 2012 <br /> PROPERTY/BUSINESS OWNER[] OPE ATOR/MANAGER ❑ OTHER AUTHORIZED AGENTaService Manager <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 COUN"TY ENVIRONMtiNTAL HEALTH Dt:PAIt'TMEN'r 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: Permit Approval US T 12e—jl&�F/r <br /> COMMENTS: RECEIVED <br /> Replace faulty sensor in 91 fill sump. JA114 G 4 2012 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: LV we EMPLOYEE#: q vJ 0 DATE: I �4 (2-- <br /> ASSIGNED <br /> ASSIGNED TO: N Pa Io-W EMPLOYEE#: �(v e DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j 77- P 1 E: '�-3 0j <br /> Fee Amount: $375.00 Amount Paid $375.00 Payment Date January 23,2012 <br /> Payment Type Credit Card Invoice# Check# Received By: <br /> Confirmation #A56204 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />