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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH SARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION ( 0011 -99- 66-79 3 cJ <br /> OWNER/OPERATOR <br /> BP ARCO WEST COAST PRODUCTS LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ARCO-2093 <br /> SITE ADDRESS 3425 TRACY BLVD. TRACY 95376 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT,SUITE G <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> DUBLIN CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551.7555 <br /> PHONE V EXT• BOS DISTRICTS LOCATION•3CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> Gettler Ryan Inc. PHONE#925 551.7555 EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 6805 SIERRA COURT,SUITE G ( 925 ) 551-7888 <br /> CITY DUBLIN STATE CA ZIP 94568 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application anork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FERE d that the_wand <br /> ---- <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT Ix Agent for Owner AbA <br /> If APPLICANT is not the BILGING PARTY,proof of authorization to sign is required Title , <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property 1R <br /> ft <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental asses <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th mchilne,J1 I <br /> provided to me or my representative. Jp `018 <br /> TYPE OF SERVICE REQUESTED: <br /> Z LA�71- <br /> COMMENTS: �Nr <br /> REMOVE EXISTING DROP TUBES AND VENT BALL FLOAT CAGES AND INSTALL NEW FRANKLIN FUELS FFS-OPV OVERFILL <br /> PROTECTION VALVES IN ALL LISTS <br /> ACCEPTED BY: 0A Z'o EMPLOYEE#: DATE: 2 �%t <br /> ASSIGNED TO: -'\I) L�`� r EMPLOYEE#: DATE: L� /L� <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: ,3 Q <br /> Fee Amount: c, Amount Paid �slO.Db Payment Date <br /> Payment Type Invoice# Check# IZ7S-- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />