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9255517888 Line 1 11:38:40 05-14-2013 3/11 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# 8151WIft REQUEST SERVICE STATION FLA 000 6773 OWNER/OPERATOR BP West Coast Products LLC CHECK if BILLINGADORESS❑ FACILITY NAME ARCO-2186 SITE ADDRESS 3212N CALIFORNIA STOCKTON 95204 Street Number Direction Street Name city- Zip Coda HOME or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court,Suite J Street Number Street Name CITY STATE ZIP Dublin CA 94568 PHONE#f Exr. APN# LAND USE APPLICATION# ( 925) 551-7555 125-320-01 PHONE#2T BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR LIDDY MCKENZIE CHECK IT BILLING ADDRESS BUSINESS NAME Gettler Ryan Inc. PHO 551-7555 EXT. HOME or MAILING ADDRESS FAX# 6747 6747 Sierra Court,Suite J ( 925) 551-7888 CITY Dublin STATE CA ZIP 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. I also certify that I have prepared this application and that the rk to be or d w' e,done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL S. APPLICANT'S SIGNATURE: DATE:05/14/2013 PROPERTY/BUSINESs OWNER❑ OPERATO ANAGER ❑ OTHER AUTHORIZED AGENT C Agent for Owner /f APPLICANT is not the BILLING PARIT,proof of authorization to sign is required Tale 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 to 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. TYPE OF SERVICE REQUESTED: UST RETROFIT P ENT COMMENTS: StCVVED REPLACE POSITION SENSITIVE SENSOR(PART NO 794380-323)ON 87 MASTER FILL SUMP MAY 14 2013 SAN JOAC UIN COUNTY FNVIR MENTAL NEALTIri C I PARTMENT ACCEPTED BY: G ! 11 s EMPLOYEE#: r�/ u DATE: ASSIGNED TO: / ,v` EMPLOYEE#: b� DATE: Date Service Completed (if already completed): SERVICE CODE: P i E: 230 Fee Amount: _ Amount Paid 3-75-, 0 0 Payment Date 14 Payment Type 1 C— Invoice# Check# Received By: REVD I48D 11/1025 102 712003 (.:z 14 7 1 SR FORM(Golden Rod)