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9255517888 Line 1 11•)7:28 a.m. 05-22-2009 3/13 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# SERVICE STATION 1P7-7 ECS �- OWNER i OPERATOR CHECK if BILLING ADDRESS D BP West Coast Products LLC FACILITYNAME ARCO-2186 SITE ADDRESS 3212 N CALIFORNIA STOCKTON 95204 Street Number Direction Street Name city Zip Code HOME or AVAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court,Suite J Street Number Street Name CITY STATE ZIP Dublin CA 94568 PHONE#1 EXT• APN# LAND USE APPLICATION# ( 925 ) 551-7555 1 t PHONE#2 EXT. BOS DISTRICT ATI1N CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS BUSINESS NAME Gettler Ryan Inc. PHONE# 551-7555 EXT. 925 HOME or MAILING ADDRESS FAX# 6747 6747 Sierra Court,Suite J ( 925 ) 551-7888 CITY Dublin STATE CA Zip 94568 BILLING ACKNOWLEDGEMENT: I, 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. 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 COUNTY Ordinance Codes,Standards,STATE and FEDE L laws. APPLICANT'S SIGNATURE: DATE: Sr L PROPERTY/BUSINESS OWNER❑ OPERATOR/MANA 'R ❑ OTHER AUTHORIZED AGENT�r Agent for Owner If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is provided to me or my representative. :) VT TYPE OF SERVICE REQUESTED: UST RETROFIT RECEIVE COMMENTS: REPLACE POSITION SENSITIVE SENSOR(PART NO 794380-323)ON 91 T3 FILL SUMP MAY 2 2 2 09 SAN JOAQUIN CUNTY ENVIRONMEN AL HFAITH DEPAR ENT ACCEPTED BY: �r t ` EMPLOYEE#: O3 Li DATE: 5 ZZCO ASSIGNED TO: V I_�� EMPLOYEE#: (Ej j�j DATE: S Date Service Completed (if already completed): SERVICE CODE: j G C8 P/E: Fee Amount: 31 S ,v Amount Paid 31 D Payment Date S zz p Payment Type Invoice# 'L Check# Rec ived By: EHD 48-02-025 Wa�/¢'� A'[7 6 SR FORM(Golden Rod) REVISED 11/17/2003