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97;;551;19 Line 7:34a.m. 09-15-2008 3/10 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY [D # SERVICE REQUEST # SERVICE STATIONI�(}0h'h��i' PHONE # 925 EXT.551-7555 HOME Or MAILING ADDRESS EMPLOYEE #: j > Z ( OWNER / OPERATOR ASSIGNED TO: Q A_ e- u 6747 BP West Coast Products LLC ( 925 ) CHECK If BILLING ADDRESS FACILITY NAME ARCO 2130 STATE CA ZIP 94568 SITE ADDRESS 7906 N EL DORADO ST Amount Paid 16315: (040 STOCKTON 95210 Street Number Direction Street Name city Zi Code 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 C - 7 _. 3 5'c) -- l b PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR LIDDYMCKENZIE CHECKifBILLINGADDRESSCI BUSINESS NAME Gettler Ryan Inc. PHONE # 925 EXT.551-7555 HOME Or MAILING ADDRESS EMPLOYEE #: j > Z ( FAX # ASSIGNED TO: Q A_ e- u 6747 6747 Sierra Court, Suite J ( 925 ) 551-7888 CITY Dublin STATE CA ZIP 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 all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: //J DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR / 1VIANACER 0 OTHER AUTHORIZED AGENT Agent for Owner IfAPPLICANT is not the BILLING PARTY—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: UST RETROFIT COMMENTS: REPLACE POSITION SENSITIVE SENSOR ACCEPTED BY: C, L -k \-, E EMPLOYEE #: j > Z ( DATE C� / U ASSIGNED TO: Q A_ e- u EMPLOYEE #: DATE: 9 Date Service Completed (if already completed): SERVICE CODE: P 1 E: �y p Fee Amount: - ,S IS-. Li; Amount Paid 16315: (040 Payment Date 471157,0 Payment Type C--- Invoice # Check # Received By: -446 EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003