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9255517888 Line 110 5 a.m. 12-31-2009 3/14 <br /> ✓Al\ VVA e-1 V1\11 -.L1\711\Vl\11-11 AL 11L'AL 111 Al\11fiL'1\A <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# � SERVIPE RE � <br /> 67.SERVICE STATION A Dcc)3 67- <br /> OWNER <br /> MZOWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACILITY NAME ARCO 2093 <br /> SITE ADDRESS 3425 TRACY BEND TRACY 95376 <br /> Street Number Direction Strict Name Ci ZI Code <br /> HOMED MAILING ADDRESS (If Dtftrent from Site Address) 6747SierriCourt,Suite J <br /> Street Nu m ber Street Nance <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 � 'g V ID <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR i SERVICE REQUESTOR <br /> REQUESTOR LIDDY MCKENZIE CHECK if BILLING ADDRESS D <br /> PHONE# ExT. <br /> BUSINESS NAME <br /> Gettler Ryan Inc. 1 925 551-7555 <br /> HOME Or MAILING ADDRESS FAX# <br /> 6747 Sierra Court,Suite J ( 925 ) 551-7888 <br /> CITY Dublin STATE CA ZIP 94568 <br /> BILLING ACKNOWLEDGEMENT: I, 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY.Ordinance Codes,Standards,STATE and FEDE laws. <br /> APPLICANT'S SIGNATURE: DATE: / Z, A leo <br /> PROPERTY/BUSINESS OWNER❑ OPER R/MANAGER ❑ OTHER AUTHORIZED AGENT[;r Agent4orownilr <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 /> COMMENTS: RECEIVED <br /> REPLACED 87&91 AUX SIPHON JETS, PERFORM LEAK DETECTION TEST. DEC 3 1 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEAT TH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: LT 6 3 DATE: <br /> ASSIGNED TO: ` EMPLOYEE#: `fL DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 19V PIE: <br /> Fee Amount: 3 S,-"o Amount Paid 3 (k S Payment Date '31 6 <br /> Payment Type IK t CQ Invoice# Gbeck# Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />