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19255517888 Main Fax GETTLER RYAN INC #12)7 p.m. 09-20-2007 3/12 <br />SAN .TOAQUIN COUNTY ENVIRONMENTAL HEALTH DRTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />SERVICE STATION <br />SEP 2 1 <br />�' 7 7 -� <br />i`C C S 0 > `� <br />OWNER I OPERATOR <br />EXT. <br />551-7555 <br />SAN 30ACIUIN <br />ENVIR <br />CHECK If BILLING ADDRESS <br />BP West Coast Products LLC <br />HEALTH DEPARTMENNMENTAL T <br />FACILITY NAME ARCO -2186 <br />SITE ADDRESS 3212 <br />N <br />CALIFORNIA <br />I <br />6747 Sierra Court, Suite J <br />STOCKTON <br />95204 <br />Street Number <br />Direction <br />Street Name <br />citv <br />Zip Code <br />P 1 E: <br />Fee Amount: L , <br />Amount Paid <br />HOME or MAILING ADDRESS (If Different from Site Address) 6747 <br />6747 Sierra Court, Suite J <br />� <br />Street Number <br />Street Name <br />CITY <br />STATE Zip <br />Dublin <br />CA 94568 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 925 ) 551-7555 <br />_' t - ( / <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />LIDDY MCKENZIE <br />SEP 2 1 <br />BUSINESS NAMEPHONE# <br />Gettler Ryan Inc. <br />COUNTY <br />EXT. <br />551-7555 <br />SAN 30ACIUIN <br />ENVIR <br />925 <br />HEALTH DEPARTMENNMENTAL T <br />HOME or MAILING ADDRESS <br />FAx # <br />t) 3 Z I <br />6747 <br />6747 Sierra Court, Suite J <br />( 925 ) <br />551-7888 <br />CITY Dublin <br />STATE CA <br />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 the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERA ws. <br />APPLICANT'S SIGNATURE: DATE: "i ! 2 Lo <br />�-7( rT- <br />PROPERTY / BUSINESS OWNER OPERATOR / AN OTHER AUTHORIZED AGENT I 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 environmentaUsite 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 />Drovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: UST RETROFIT <br />COMMENTS: <br />SEP 2 1 <br />REPLACE POSITION SENSITIVE SENSOR (PART NO 794380-323) <br />COUNTY <br />SAN 30ACIUIN <br />ENVIR <br />HEALTH DEPARTMENNMENTAL T <br />ACCEPTED BY: t)C _ 1 Li t k -A <br />EMPLOYEE #: <br />t) 3 Z I <br />DATE: t Li <br />ASSIGNED TO: ��J /J ( <br />EMPLOYEE #: <br />?� (7 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: L , <br />Amount Paid <br />lkzqLf a�) <br />Payment Date 1 a( O% <br />� <br />_ <br />Payment Types}-� <br />Invoice # <br />Check # <br />Received By: <br />SR FORM Golden Rod) <br />EHD 48-02-025 � �- � � � � 1 <br />REVISED 11/17/2003 <br />