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SAN JOAQUIOOUNTY ENVIRONMENTAL HEALTUAPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # lo LIDDYMCKENZIE SERVICE REQUEST # SERVICE STATION I j 3C, 0C; DATE: PHONE # ExT. OWNER/ OPERATOR SERVICE CODE: f 9 - 925 BP West Coast Products LLC HOME or MAILING ADDRESS CHECK if BILLING ADDRESS FACILITY NAME ARCO 5450 Payment Date 6805 Sierra Court, Suite G SITE ADDRESS 1617 W FREMONT STREET CITY Dublin STOCKTON 95203 Street Number Direction Street Name SR FORM (Golden Rod) city Zip Code 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 # LAND USE APPLICATION # ( 925 ) 551-7555 214 18 020 PHONE #2 EXT. BOS�D.ISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR EMPLOYEE #: lo LIDDYMCKENZIE CHECK If BILLINGADDRESS� BUSINESS NAME Gettler Ryan Inc. Y DATE: PHONE # ExT. SERVICE CODE: f 9 - 925 551-7555 HOME or MAILING ADDRESS Fee Amount: - -- FAX # Payment Date 6805 Sierra Court, Suite G ( 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: DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR /N ER ❑ OTHER AUTHORIZED AGENT W Agent for Owner IfAPPL/CANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property IgF,a d at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sitCIVa T information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sl�Iq�..,D provided to me or my representative. A i t- _ ➢ vv�� TYPE OF SERVICE REQUESTED: UST RETROFIT COMMENTS: HEATH CONVERTING HEALY VACUUM ASSIST SYSTEM TO EMCO WHEATON BALANCE SYSTEM PER EXECUTIVE ORDER VR -204. o 14 ACCEPTED BY: Ivy,fes, L-- EMPLOYEE #: lo DATE: 1 ASSIGNED TO: h2zvil e� EMPLOYEE M /412-1 DATE: Date Service Completed (if alreaNy completed): SERVICE CODE: f 9 - PIE: 2.7 olp 7 Fee Amount: - -- Amount Paid �'a D (� Payment Date F1141 Payment Type Invoice # Check # 57 Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)