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9J5551788'j Line 11•n9•^1 a.m. 07-01-2009 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 6773 <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME ARCO-2186 <br /> SITE ADDRESS 3212 N CALIFORNIA STOCKTON 95204 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court, Suite J <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#Z EXT. APN# LAND USE APPLICATION# <br /> ( 925) 551-7555 125-320-01 <br /> --7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> LIDDY MCKENZIE CHECK ifBILLING ADDRESS <br /> PHOKIPBUSINESS NAME Gettler Ryan Inc. ( 551-7555 EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 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 1 have prepared this application and that the NGork to be performed will be done in accordance with all SAN JoAQvrN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL a�vs. <br /> APPLICANT'S SIGNATURE: ` - DATE:07/01/2009 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT Agent for Owner <br /> If APPLICANT is not the BILLING PAR7T—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 environmentaUsite assessment <br /> information to the SAN JOAQULIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT as soon as it is available and at the same time it js <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST RETROFIT <br /> COMMENTS: 1 QJ <br /> REPLACE POSITION SENSITIVE SENSOR (PART NO 794380-323)ON 87 MASTER FILL SUMP <br /> UNT`f <br /> ��N1�E <br /> C r1NS, qE p MFS <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid 11 1 131,5-. D 6 Paymen ate -7 ) 0 <br /> Payment Type IInv..oice1# QCheck## Received By: <br /> EHD 48-02-025 �U N M`'V` C ( � / �S SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />