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9255517888 Line 1050 p.m. 01-26-2009 2/8 <br /> 40 <br /> SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERVICE STATION 3, ( 7 S ' 00 S 15` <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FAciury NAME ARCO 2093 <br /> SITE ADDRESS 3425N Tracy Blvd. Tracy 95376 <br /> Street Nu or <br /> DirMlan <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 Sierra Court,Suite J <br /> Sheet Number Street Name <br /> STATE ZIP <br /> CITY DublinCA 94568 <br /> PHONE#1 W. APN# / LAND USE APPLICATION# <br /> ( 209 ) 835.1605 l `-f - l,ft a C; <br /> PHONE#Z EXT. BOS DISTRICT LACATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE CHEGKIfBILLINGADDRE55El <br /> PHONE# ' <br /> BUSINESS NAME <br /> Gettler Ryan Inc. 1 209 835.1605 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 Sierra Court,Suite J ( 209 559-7888 <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 Hr-Aum 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 1 have prepared this applicationd that;he work to be performed will be done in accordance with all SAN JOAQUIN <br /> UN <br /> COTY Ordinance Codes,Standards,S'rAi, FEn L laws. <br /> APPLICANT'S SIGNATURE: DATE: 1/23/2009 <br /> PROPERTY/BUSINESS OWNER CI O RAT N1t AGER ❑ OTHER AUTHORIZED AGENT Agent <br /> If APPLICANT is not the %7'proof of authorization to sign is required Title <br /> At 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: s ' 6 � <br /> Replacement of existing tank mag probe for 87 UST with new mag probe VR846390 with 2"gasoline float"�✓� /(o�o{� <br /> ooti�,�co Op9 <br /> ACCEPTED BY: L EMPLOYEE#: G Z_t DATE; 1 Z G <br /> AssiGNED To: EMPLOYEE M /l' DATE: �' l <br /> Date Service Completed (if already completed): SERVICE CODE: c h' P i s v <br /> Fee Amounts 3 Amount Paid 3 Payment Date <br /> Payment TypeIy) Invoice# Check# Received By: <br /> EMD as-02-dz� ` ` 't` •, �' SR FORM(Goid9rtRod) <br /> REVISED 11/1712W3 <br />