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19255517865 Main Fax GETTLER RYAN INC 01:54:36 p.in. 07-31-2007 3/10 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# SERVICE STATION ?-- "700 '/ -1' OWNER i OPERATOR CHECK if BILLING ADDRESS BP West Coast Products LLC FACILITY NAME YOSEMITE ARCO SITE ADDRESS 1711 E YOSEMITE AVE MANTECA 95336 Street Number Direction Street Name Zip 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 Exr. APN# LAND USE APPLICATION# ( 925 ) 551-7555 PHONE#2 Exr. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR LIDDYMCKENZIE CHECK if BILLING ADDRESS BUSINESS NAME Gettler Ryan Inc. PHD925 551-7555 Exr. HOME or MAILING ADDRESS FAX# 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 andthat the w to be prformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL la APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MA GER ❑ OTHER AUTHORIZED AGENT RI-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. DAY M�Iv a TYPE OF SERVICE REQUESTED: UST RETROFIT RF JE COMMENTS: JUS 3 1 2001 REPLACEMENT OF CPU PROCESSOR AND REPROGRAMMING OF CPU, SAN JOAOUIN LOUNV ENVIRONMENTAL T HEALTH pF_PARTMEN ACCEPTED BY: o / )3 EMPLOYEE#: (D'�'S 3 DATE: ASSIGNED TO: 2� (� (U EMPLOYEE#: () DATE: Date Service Completed (if already completed): SERVICE CODE: rl Qj P 1 E: 2-.7 O Fee Amount: Amount Paid 2, Payment Date 7/311 Payment Type ,y` � Invoice# Check# Received By: EHD 48-02-025 J �S3 T SR FORM(Golden Rod) REVISED 11/17/2003