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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property COMMENTS: CONVERT EXISTING 91 UST TO DIESEL, CONVERT EXISTING 89 TO 91 UST. REMOVE AND REPLACE EXISTING DISPENSERS AND UDC'S FACILITY ID SERVICE REQUEST # SERVICE STATION PHONE # EV. SERVICE CODE: OWNER / OPERATOR 9251551-7555 CHEVRON PRODUCTS COMPANY CHECK if BauNGADORESs FACILITY NAME CHEVRON SS#201383 FAX # SITE ADDRESS 1960 W I 11TH STREET I ( 925 ) TRACY 95376 Street Number Diredioll Dublin CA C& ZillCode HOME or MAILING ADDRESS (If Different from Site Address) 6805 Sierra Court, Suite G Street Number Street Name CITY STATE ZIP Dublin CA 94568 PHONE #1 ExT• APN IF LAND USE APPLICATION # ( 925 ) 551-7555 PHONE #2 ExT• ( 1 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE , , r REQUESTOR LIDDYMCKENZIE COMMENTS: CONVERT EXISTING 91 UST TO DIESEL, CONVERT EXISTING 89 TO 91 UST. REMOVE AND REPLACE EXISTING DISPENSERS AND UDC'S CHECK If BILLING ADDRESS BUSINESS NAME Gettier Ryan Inc. ASSIGNED TO: PHONE # EV. SERVICE CODE: P I E: 9251551-7555 Amount Paid HOME or MAILING ADDRESS Payment Type FAX # Check # 6805 Sierra Court, Suite G ( 925 ) 551-7888 CITY STATE ZIP Dublin CA 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. I also certify that I have prepared this application and that the work to be performed will be done in accordance with al] SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 711 Z_ PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANA ER ❑ OTHER AUTHORIZED AGENT C r Agent for caner If APPLICANT is not the BILLING PARm proof of authorization 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: DISPENSER/UDC UPGRADE AND TANK CONVERSION COMMENTS: CONVERT EXISTING 91 UST TO DIESEL, CONVERT EXISTING 89 TO 91 UST. REMOVE AND REPLACE EXISTING DISPENSERS AND UDC'S ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003