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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # ;SERVICE REQUEST # SERVICE STATION O UO.�(o� 7 SOdl _ OWNER / OPERATOR CHECK If BILLING ADDRE55 ] BP ARCO WEST COAST PRODUCTS LLC FACILITY NAME ARCO-2093 SITE ADDRESS 3425 TRACY BLVD. TRACY 95376 Street Number Direction I Street Name citv Zin 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 PHONE #2 ExT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR MERLIN BOWEN CHECK if BILLING ADDRESS BUSINESS NAMEPHONE # Exr. Gettler Ryan Inc. 925 551 .7555 HOME Or MAILING ADDRESS FAX # 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 t work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FED laws . APPLICANT ' S SIGNATURE : DATE : PROPERTY / BUSINESS OWNER ❑ O BATOR / NAGER ❑ OTHER AUTHORIZED AGENT Agent for Owner If APPLICANT 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 : Drop Tube Replacement COMMENTS : REMOVE EXISTING DROP TUBES AND INSTALL NEW FRANKLIN FUELS FFS-OPV OVERFILL PROTECTION VALVES IN 87 tank. ACCEPTED BY : X1W ��_ EMPLOYEE #: DATE : 4j 22 ASSIGNED TO : Oa �rO L Pr `e� I -D EMPLOYEE #: DATE : Date Service Completed ( if already completed ) : SERVICE CODE : l Gfcr� _ 2100 P I E : 2-3 C) G! Fee Amount: WOV414E5�p v a Amount Paid Payment Date Payment Type Invoice # Check # Received By : EHD 48-02-025 SR FORM (Golden Rod) REVISED 11 / 17/2003