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9255517888 Line 08:54:35 07-03-2014 3/11 <br /> SAN JOAQUW COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 3 X260 7000J <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO 6080 <br /> SITE ADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number Direction Street Name city Zip Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 Sierra Court,Suite G <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHDNE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551.7555 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE <br /> CHECK If BILLING ADDRESSIZ <br /> BUSINESS NAME Gettler Ryan Inc. PHONE#925 551-7555 ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> 6805 Sierra Court,Suite G ( 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 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 /> 1 also certify that I have prepared this application and that the rk to be performed will be done in accordance with all SAN JOAQUry <br /> COUNTY Ordinance Codes,Standards, STATE and FEDE w <br /> APPLICANT'S SIGNATURE: DATE: I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTIIORIZED AGENT Agent 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: ��� <br /> N T <br /> REPLACE A POSITION SENSITIVE SENSOR(P/N 794380-323) ON Diesel Fill Sump L 03 <br /> J04QUAAN 2 4 <br /> cou <br /> ACCEPTED BY: I. EMPLOYEE#: DATE: —7 <br /> ASSIGNED TO: EMPLOYEE M DATE: 7 /I f <br /> Date Service Completed (if already completed): SERVICE CODE: �Q�/ P I E:230& <br /> Fee Amount: O Amount Pai 37S Payment Date <br /> Payment Type `, Invoice# Check# �j A 3�3T Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Received Time Jul. 3. 2014 8:44AM No- 6491 <br /> �V 1 � <br />