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0 SAN JOAQUSOUNTY ENVIRON&TAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />LIDDYMCKENZIE <br />SERVICE REQUEST # <br />SERVICE STATION <br />BUSINESS NAME Gettler Ryan Inc. <br />(2 03 C I <br />PHONE # <br />-4�OM %02- 6?P <br />OWNER/ OPERATOR <br />925 <br />551-7555 <br />BP West Coast Products LLC <br />FAX # <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME ARCO 2093 <br />( 925 ) <br />551-7888 <br />SITE ADDRESS 3425 <br />STATE <br />TRACY BLVD <br />Dublin <br />TRACY <br />95376 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 6805 <br />Sierra Court, Suite G <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Dublin <br />CA 94568 <br />PHONE #1 EXT• <br />APN # <br />LAND USE APPLICATION # <br />( 925) 551-7555 <br />2 I tt <br />lu 0 0 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR U <br />REQUESTOR <br />LIDDYMCKENZIE <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME Gettler Ryan Inc. <br />PHONE # <br />Exr <br />925 <br />551-7555 <br />HOME or MAILING ADDRESS <br />FAX # <br />6805 Sierra Court, Suite G <br />( 925 ) <br />551-7888 <br />CITY <br />STATE <br />ZIP <br />Dublin <br />CA <br />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 law l <br />APPLICANT'S SIGNATURE: '/''//� DATE: � /)1/ /% <br />4- <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT a 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 P) lent <br />Information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as It IS available and at the sajl� <br />provided to me or my representative. I CE/1� <br />TYPE OF SERVICE REQUESTED: UST RETROFIT AUG12 14 <br />COMMENTS: N J0AQv' <br />HEA TH t),.. N— Al <br />IL <br />CONVERTING HEALY VACUUM ASSIST SYSTEM TO EMCO WHEATON BALANCE SYSTEM PER EXECUTIVE <br />ORDER VR -204. o <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Fee Amount: 3`j Amount <br />Payment Type V I Invoice # <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />EMPLOYEE #: 2,,� -7( I DATE: el i <br />EMPLOYEE #: / ( DATE: <br />SERVICE CODE: <br />D Payment Date <br />Check # 1 RecE <br />PIE: 7 3 o <br />ved By: <br />SR FORM (Golden Rod) toc�2?4� <br />Z� <br />