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192555178£18 Main Fax GETTIER RYAN INC 0 :41 p.m. 08-28-2007 3111 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # SERVICE STATION 4� f t-1 �, 5-2 (D6 s�I 7 �5 OWNER J OPERATOR COON", CHECK if BILLING ADDRESS ` BP West Coast Products LLC HOME or MAILING ADDRESS FACILITY NAME ARCO 2093 FAX # SITE ADDRESS 3425 I TRACY BLVD I TRACY 95376 Street Number Direction ZIP 94568 Street Name city Zip Cod Amount Paid �' `, Payment Date .L�i p 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 #1 EXT. APN # LAND USE APPLICATION # ( 925 ) 551-7555 PHONE #2 Err BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR LIDDY MCKENZIE CHECK If BILLING ADDRESS BUSINESS NAME Gettler Ryan Inc. REPLACE POSITION SENSITIVE SENSOR PH925 551-7555 EXT. COON", JOPOVIN SvkRONME T E HOME or MAILING ADDRESS FAX # ACCEPTED BY: �,� 6747 6747 Sierra Court, Suite J ( 925 ) 551-7888 CITY STATE CA ZIP 94568 Dublin P ! E: Fee Amount, )-ci� ®� 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 t t th to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FE R APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER ❑ OPERAT M AGER 0 OTHER AUTHORIZED AGENT 0 Agent for Owner IfAPPLICANT is not the BILLING TY, 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 COMMENTS: REPLACE POSITION SENSITIVE SENSOR ASG 2 9 COON", JOPOVIN SvkRONME T E {f �L V, DEPAR ACCEPTED BY: �,� EMPLOYEE #:uv DATE: ASSIGNED TO: EMPLOYEE #: 5 (, -Z, DATE: Date Service Completed (if alrea completed): SERVICE CODE:Tq P ! E: Fee Amount, )-ci� ®� Amount Paid �' `, Payment Date .L�i p Payment Type�pinvoice # Received By: (� EHD 48-02-025 �'l `�� IA SR FORM (Golden Rod) REVISED 11/1712003