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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # SERVICE STATION rO p, &3-7 OWNER/ OPERATOR BUCKETS AND DROP TUBES TO VR -102 EXECUTIVE ORDER. REPLACE ALL TURBINES WITH NEW TURBINES CHEVRON PRODUCTS COMPANY CHECK If BILLING ADDRESS ❑ FACILITY NAME CHEVRON SS#307709 ELECTRICAL J BOXES IN SUMPS. COLD START VEEDOR ROOT TLS -350 WITH UPGRADED SOFTWARE. SITE ADDRESS HOME or MAILING ADDRESS ACCEPTED BY: FAX # 10858 SIERRA COURT, SUITE G TRINITY PARKWAY STOCKTON 95219 Street Number Direction DUBLIN Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT, SUITE G Payment TypeV/ Street Number Street Name CITY STATE ZIP DUBLIN CA 94568 PHONE #1 EXT. APN # 15 J LAND USE APPLICATION # ( 925 ) 551.7555 142-6 PHONE #2 ExT. BOS DISTRICTLOCATION CODE ( ) 0U p CONTRACTOR / SERVICE REQUESTOR REQUESTOR S'r MERLIN BOWEN CHECK If BILLING ADDRESS 13 BUSINESS NAME Gettler Ryan Inc. BUCKETS AND DROP TUBES TO VR -102 EXECUTIVE ORDER. REPLACE ALL TURBINES WITH NEW TURBINES PHONE# 551.7555 EXT. RAISE EXISTING TLM AND ELECTRICAL J BOXES IN SUMPS. COLD START VEEDOR ROOT TLS -350 WITH UPGRADED SOFTWARE. 925 HOME or MAILING ADDRESS ACCEPTED BY: FAX # 6805 SIERRA COURT, SUITE G ( 925 ) 551-7888 CITY STATE ZIP DUBLIN CA 94568 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. e1 A APPLICANT'S SIGNATURE: *�"[ DATE:_/ PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT EX Agent for Owner QCAw ENT ffAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Titte VED AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property loAVRalt above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment 2018 information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thea e►Q'WUINsCCUNTy provided to me or my representative. li NVIRONMENTAL TMENT TYPE of SERVICE REQUESTED. DISPENSER REPLACEMENT AND CHANGE TO OPW VR 102 S'r COMMENTS: REMOVE/REPLACE WITH 6 NEW GILBARCO ENCORE DISPENSERS WITH NEW HANGING HARDWARE. INSTALL OPW SPILL BUCKETS AND DROP TUBES TO VR -102 EXECUTIVE ORDER. REPLACE ALL TURBINES WITH NEW TURBINES AND PLLD'S, FLEX CONNECTORS AND BALL VALVES. REPLACE ALL TANK SUMP SENSORS WITH NEW VR 209 SENSORS. RAISE EXISTING TLM AND ELECTRICAL J BOXES IN SUMPS. COLD START VEEDOR ROOT TLS -350 WITH UPGRADED SOFTWARE. ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Complete` (if already completed): SERVICE CODE: I P 1 E: JGV Fee Amount: — Amount Paid ! f .• Payment Date 4/1-7 /1-7 D/ Payment TypeV/ IInvoice # Check # 1 3 3 Received By: J-5, EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003