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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />SERVICE STATION <br />A0003400 <br />-s; -4d0&8421 <br />OWNER/ OPERATOR <br />BP West Coast Products LLC <br />CHECK If BILLINGADDRESSE] <br />FACILITY NAME ARCO 5450 <br />SITE ADDRESS 1617 <br />w <br />I <br />Fremont <br />I <br />Stockton <br />95203 <br />Street Number <br />Direction <br />( 925) <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 6805 <br />Sierra Court., Suite G <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Dublin <br />CA 94568 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 925) 551.7555 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Merlin Bowen <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Gettler Ryan Inc. <br />PHONE# <br />551.7555 Exr <br />92 <br />HOME or MAILING ADDRESS <br />FAX # <br />6805 <br />Sierra Court, Suite G <br />( 925) <br />551-7888 <br />CITY Dublin <br />STATE CA <br />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: Lr-- DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 1;r Agen4 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 operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sPAsment <br />information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thelq;wItt is <br />provided to me or my representative. - Fni <br />TYPE OF SERVICE REQUESTED: UST RETROFIT ITUV <br />COMMENTS: HSAIL" RpM j <br />REPLACE EXISTING OPW SPILL BUCKETS WITH SAME AND REPLACE EXISTING UST SUMP SENSOTMorr <br />WITH 208 SENSORS. <br />ACCEPTED BY: M , n/110—t- ` ! EMPLOYEE #: -7�Q DATE: �( /7 (I 3 <br />ASSIGNED TO: K t t f C ' C/ 4 EMPLOYEE #: 142— 1 DATE: (11 f L 3 <br />Date Service Completed (if already completed): SERVICE CODE: 1 �( PIE: <br />,2 gj p8 <br />Fee Amount: 137.5- Amount PaidF,37,5. OO Payment Date ( 7 <br />Payment Type Invoice # Check # ,j 33 Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />