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192555.17888 Main Fax 0 GETTLER RYAN INC 2:00 p.m. 05-31-2007 3/11 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# SERVICE STATION �2 W r OWNER/OPERATOR .' CHECK if BILLING ADDRESS ARCO) FACILITY NAME ARCO-2133 SITE ADDRESS 2908 Benjamin Holt Drive Stockton Street Number I Direction I Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court, Suite J Street Number Street Name CITY Dublin STATE CA Zip 94568 PHONE#1 ET• APN# LAND USE APPLICATION# ( 925) 551-7555 ��t 5�- 3 O - PHONE#2 EXT. BOS DISTRICT LACATION CODE 1 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR LIDDY MCKENZIE CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Gettler Ryan Inc. 92s 551-7555 HOME or MAILING ADDRESS 6747 Sierra CourtSuite J FAx# ( 925 ) 551-7888 CITY Dublin STATE CA ZIP 9456$ BILLING ACKNOWLFDGEME NT: 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 orm. I also certify that 1 have prepared this application and that e w to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FERE la I APPLICANT'S SIGNATURE: DATE: { p PROPERTY/BUSINESS OWNER❑ OPERATOR/M NAGER ❑ OTHER AUTHORIZED AGENT WI Agent for Owner If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 CEI�/�® COMMENTS: 0 9 2007 REPLACE A Veeder-Root POSITION SE SITIVE SENSOR(P/N 794380-323) SUN 1 V W11"Imi-7OK .1 izN SAN JOAQUIN COUNT'i -- ENViRONMENTA HEAL-VN DEPARTM EW ACCEPTED BY: CL i L l W EMPLOYEE#: (ice L DATE: r / f ASSIGNED TO: Y � EMPLOYEE#: (_S,S DATE: Date Service Completed (if already completed): SERVICE CODE: 1 P 1 E: Fee Amount: S_cro Amount Paid �� 0-C, F Payment Date p-j Payment Type VjG- Invoice# Check# ReIceived By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003