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0 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # GAS STATION HOME Or MAILING ADDRESS 5805 SIERRA COURT, SUITE G RO yMEH ��-bL 7 ?5 0 ':. Do] OWNER /OPERATOR STIP ZIP 94568 BP ARCO EMPLOYEE M CHECK If BILLINGADDRESS� FACILITY NAME BP ARCO SS#2093 EMPLOYEE M SITE ADDRESS N TRACY BLVD TRACY y 3425 Street Num 'on Street Name / /s �. HOME Or MAILING ADDRESS (If Different from Site Address) Ch #q� a F. law 11 V Street Number Street Name CITY STATE ZIP SEP zut PHONE #1 EXT. 209.835-1605 APN # 4 LAND USE APPLICATION # ETe. ( > , :,-�..RO„--Mnj� PHONE #2 EXT. BOS DISTRICT•-� LOCATIIOI�N CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR MERLIN BOWEN CHECK If BILLING ADDRESS BUSINESS NAME GETTLER-RYAN INC RECEIV PHONE# ExT. 25.551-7555 HOME Or MAILING ADDRESS 5805 SIERRA COURT, SUITE G RO yMEH ��`# )925.551-7888 CITY DUBLIN STIP ZIP 94568 ITA 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 fort. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:. &2Z !-� DATE: 9/01/2015 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT N agent for contractor If APPLICANT is not the BILLING PARTY. proof of authorizadon 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 environmentallsite 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: REPAIR F A Y,4e COMMENTS: RECEIV REPLACEMENT OF EXISTING ANNULAR SENSORS "LIKE FOR LIKE" IN ALL TANKS. sEP a/ RO yMEH NFALwcot p ACCEPTED BY: t EMPLOYEE M DATE: / ASSIGNED TO: EMPLOYEE M DATE: < Date Service Completed (if already completed): SERVICE CODE: l P ? J Fee Amount: -Occ, Amount Pai 3'70. Payment Date / /s Payment Type Invoice # Ch #q� a Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 VT :D 015 WA