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k <br />9255517888 Line � 9:07:37 07-25-2013 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />2/11 <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# Exr. <br />SERVICE REQUEST # <br />SERVICE STATION <br />'�� 0 <br />S gjCjo (c'-7 /" T C-' <br />OWNER/ OPERATOR <br />EMPLOYEE #: 76 70 <br />DATE: <br />BP West Coast Products LLC <br />EMPLOYEE #: 4 -L- I <br />CHECK If BILLING ADDRESSC� <br />FACILITY NAME ARCO 5450 <br />SERVICE CODE: I C1 <br />SITEADDRESS 1617 <br />w <br />I <br />Fremont <br />Payment Date <br />li3 <br />Stockton <br />95203 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />6747 Sierra <br />Court, Suite J <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Dublin <br />CA 94568 <br />PH0NE#1 EXT. <br />APN# <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Merlin Bowen CHECK if BILLING ADDRESS 1Z <br />BUSINESS NAME Gettler Ryan Inc. <br />PHONE# Exr. <br />HOME or MAILING ADDRESS <br />FAX # <br />6747 Sierra Court, Suite J <br />( ) 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 1 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: MWA xe,^ DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Qr _ Agent for Owner <br />IfAPPL/CANT 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'PAi LEN' <br />provided to me or my representative. �� I \!C <br />TYPE OF SERVICE REQUESTED: UST RETROFIT <br />COMMENTS: <br />REPLACE A POSSIBLE LEAKING ELECTRICAL CONDUIT PENETRATION BOOT AND OR A A COU <br />PENETRATION LOCATED IN T-1 STP SUMP REGULAR GASOLINE. <br />M <br />NIEIVTAt_ <br />HEALTH DEPARTME <br />ACCEPTED BY: , n Z1--% <br />EMPLOYEE #: 76 70 <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: 4 -L- I <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: I C1 <br />0 <br />Fee Amount: D A <br />Amount Paid 37,5°0 <br />Payment Date <br />li3 <br />Payment Type N( <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Received Time <br />J u 1.25. 2013 9 0l AM No. 3682 <br />SR FORM (Golden Rod) <br />ITY <br />VT <br />