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19255517888 Main Fax GETTLER RYAN INC ' 01 P.M. 10-10-2007 5/11 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# SERVICE STATION �1�2� 1Q C y OWNER/OPERATOR BP West Coast Products LLC CHECK If BILLING ADDRESS FACiLITY NAME ARCO 2133 SITE ADDRESS 2908BENJAMIN HOLT OR STOCKTON 95207 Str N mb r Dir tion Street Name ClIx Zip Cod 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 91 ExT. APN# LAND USE APPLICATION# ( 925 ) 551-7555 PHONE#2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR LIDDY MCKENZIE CHECK ifEIILLINGADDRESS O BUSINESS NAME Gettler Ryan Inc. PHONE 5 551-7555 t xr HOME Or MAILING ADDRESS FAX# 6747 6747 Sierra Court,Suite J ( 925 ) 551-7886 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. 7 I also certify that I have prepared this application and that the work t be rfo will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. t / APPLICANT'S SIGNATURE: DATE: `p ` U PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT liff Agent for Owner If APPLICANT is not the BILLING PARTY proof of authorizadon 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 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 N ANT COMMENTS: REPLACEMENT OF POSITION SENSITIVE SENSOR(P/N 794380-323) 0C1 1 2007 SAN JOAOUIN COVNN ENVIRONMENTP�- Ii pEPARTME ACCEPTED BY: P EMPLOYEE#: DATE: to 10 d ASSIGNED TO: EMPLOYEE#: ( DATE: t a 1011-1 Date Service Co plete (if air ady completed): SERVICE CODE: P!E. .Z-1*72" Fee Amount: 2� ,� Amount Paid ,�Il Payment Date �p t6 0 Payment Type Invoice# G6e,k-0- s `g Receiv d By: EHD 48-02-025 G SR FORM(Golden Rod) REVISED 11/17/2003 IIIJJJ"'