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1925551788FJ Main Fax . GETTLER RYAN INC 4:24 a.m. 04-29-2008 3/10 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />SERVICE STATION <br />Co 2' <br />551-7555 EXT. <br />HOME or MAILING ADDRESS <br />6747 <br />OWNER / OPERATOR <br />FAX# <br />( 925 ) <br />551-7888 <br />BP West Coast Products LLC <br />STATE CA <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME ARCO 2093 <br />SITE ADDRESS 3425 AJ,, <br />TRACT <br />BLVD <br />EMPLOYEE #: �1DATE: <br />TRACY <br />95376 <br />Street Number <br />Direction <br />EMPLOYEE #: �2 <br />Street Name <br />Date Service Completed (if aI eady completed): <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 6747 <br />6747 Sierra Court, Suite J <br />Fee Amount: <br />Street Number <br />Amount Paid C� � <br />Street Name <br />CITY <br />2C1 a $ <br />STATE ZIP <br />Dublin <br />Invoice # <br />CA 94568 <br />PHONE #1 E- <br />APN # <br />LAND USE APPLICATION # <br />( 925 ) 551-7555 <br />( L/ <br />PHONE #2 Err. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR LIDDYMCKENZIE <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Gettler Ryan Inc. <br />PH NE <br />551-7555 EXT. <br />HOME or MAILING ADDRESS <br />6747 <br />6747 Sierra Court, Suite J <br />FAX# <br />( 925 ) <br />551-7888 <br />CITY Dublin <br />STATE CA <br />ZIP 94568 <br />BILLING ACKNOWLEDGEMENT: 1, 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 a that a wo to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and DE L la <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERA(OR /AGER ❑ OTHER AUTHORIzED AGENT Wf Agent 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/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: UST RETROFIT <br />1 j <br />COMMENTS: <br />- VF <br />REPLACE POSITION SENSITIVE <br />Cm l t`�Ve C� Fl/� <br />HEAIEFLTH <br />jPPME�Ou/vey <br />ACCEPTED BY: <br />L I �, r t �O !� <br />EMPLOYEE #: �1DATE: <br />/ZLtzhr <br />4 C% <br />ASSIGNED TO: <br />14 tZ� <br />EMPLOYEE #: �2 <br />DATE: <br />Date Service Completed (if aI eady completed): <br />SERVICE CODE:( <br />P 1, <br />Fee Amount: <br />:) - cf , 0 c3 <br />Amount Paid C� � <br />Payment Date <br />2C1 a $ <br />Payment Type <br />� <br />Invoice # <br />Received By: <br />1♦r\7- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />