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09255517888 Line 1 49 1027 a.m. 05-18-2009 3/12 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 3 b 2:7 <br /> OWNER 1 OPERATOR <br /> BP West Coast Products LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ARCO 2093 <br /> SITEADDRESS 3425 TRACY BLVD TRACY -5376 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court,Suite J <br /> Street Number Street Name <br /> CITY STATE Zip <br /> Dublin CA 94568 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 925 ) 551-7555 <br /> PHONE#2 ExT. BOS DISTRICT —5- LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REOUESTOR LIDDYMCKEN23E CHECK if BILLING ADDRESS�I <br /> BUSINESS NAME Gettler Ryan Inc. PHONE# ExT. <br /> 925 551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 Sierra Court,Suite J ( 925 1 551-7888 <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 FEDERA ws. /� u <br /> APPLICANT'S SIGNATURE: op' DATE: (/✓4+�r0 " y <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER Er OTHER AUTHORIZED AGENT 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 N-( <br /> COMMENTS: RECEN <br /> REPLACE POSITION SENSITIVE SENSOR 1 % 2Qo9 <br /> i'J &r )qy��� MAY <br /> SAEN�RPd <br /> "CALTQpNMENT� 1.IT <br /> 1 DEPPR <br /> ACCEPTED BY: 0 L(`y+E; EMPLOYEE#: ©Z) DATE: <br /> ASSIGNED TO: C-41i 4 EMPLOYEE#: S-4942— DATE: - t- o <br /> Date Service Completed (if alr dy completed): SERVICE CODE: 1 Q PIE: ATO <br /> Fee Amount: [ S Ulf Amount Paid 31, S _ Payment Date S fi p <br /> Baymerrt`flrpe Invoice# Lk&2Z Z Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />