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SAN JOAQUTAUNTY ENVIRONMENTAL HEALTH IWARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION q 0 Do 3 2-+ aJf2�O6 7 Cj k <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> BP ARCO WEST COAST PRODUCTS LLC <br /> FACILITY NAME ARCO-2093 <br /> SITE ADDRESS 3425 TRACY BLVD. TRACY 95376 <br /> Street Number I Direction 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 ' FIN <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) CIO Is <br /> ® � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR MERLIN BOWEN CHECK If BILLING ADDRESS <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# 551.7555 Exr. <br /> 925 <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 9 2v f <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT q Agent for Owner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operato6111) <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/orF <br /> s <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avait e same time it is <br /> provided to me or my representative. SLE 13 2,018 <br /> TYPE OF SERVICE REQUESTED: REPLACEMENT OF 208 SENSOR IN L5 STP SUMP WITH SAME <br /> COMMENTS: ENVIR MEN IlAL <br /> REMOVED BAD 208 SENSOR IN L5 STP SUMP WITH A VEEDOR ROOT 208 SENSOR.CONFIRM NEW SENSOFHIAbWI I� " <br /> ENT <br /> ACCEPTED BY: G ` EMPLOYEE#: '£E()C,30C 37DATE: 91-2,11 Ila <br /> ASSIGNED TO: 2 �Q`- [(� EMPLOYEE#: �'EQUvOU3`{- DATE: q JZ( 1100 <br /> Date Service Completed (if already completed): SERVICE CODE: )(�!1t P I E:� <br /> Fee Amount: S(o Amount Paid# `f5% UD f �S� �Zj Payment 1Date 'ql' X <br /> Payment Type Invoice# Check# (qg3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />