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'19255517888 Main Fax • GETTLER RYAN INC 1:22 a.m. 01-15-2008 2/10 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME Gettler Ryan Inc. SERVICE EQUEST # SERVICE STATION Exr• 551-7555 36 2 % 6747 Sierra Court, Suite J �-W / OWNER I OPERATOR CITY Dublin STATE CA ZIP 94568 BP West Coast Products LLC Fee Amount: W aCi Lv tZ Amount Paid CHECK If BILLING ADDRESS FACILITY NAME ARCO 2093 I ®g Payment Type ViInvoice # SITE ADDRESS 3425 Received By: L& TRACY BLVD I TRACY 95376 Street Number Dire tion Street Name CftV 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. 925 APN #rr :Z ,,4 1 `_ i 8-�) LAND USE APPLICATION # ( ) 551-7555 PHONE #2 Exr• SOS DISTRICT 4 LOCATION CODE { ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR LIDDY MCKENZIE CHECK if BILLING ApORESSE] BUSINESS NAME Gettler Ryan Inc. ACCEPTED BY: I kq PHONE # 925 Exr• 551-7555 HOME or MAILING ADDRESS 6747 6747 Sierra Court, Suite J FAX # ( 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 t t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY OYdlnance Codes, Standards, STATE and FE RAL JkWS. APFLICANT'S SIGNATURE: DATE: -111,5106 PROPERTY / BusimESs OWNER ❑ OPERATO ! diR ❑ OTHER AUTHORIZED AGENT B Agent for Owner If APPLICANT is not the B1LLimG 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: UST RETROFIT COMMENTS: REPLACEMENT OF 8 INPUT SENSOR I/F MODULE (329358-001) AND POSITION SENSITIVE SENSOR (794380-323) ACCEPTED BY: I kq EMPLOYEE #: S �� DATE: ASSIGNED TO: N EMPLOYEE #: s(� 4 — DATE: ! t 0 Date Service Completed (if alr ady completed): SERVICE CODE: (Cf� P 19: Fee Amount: W aCi Lv tZ Amount Paid 02q4 DD Payment Date I ®g Payment Type ViInvoice # Check # Received By: L& EHD 48-02-025 L lsI -A Azo I SR FORM (Golden Rod) REVISED 11/17/2003