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9255517888 Line 1 • 0 32:31 06-12-2013 3/11 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECKIfBILLING ADORES S© FACILITY ID # SERVICE R.E UEST # SERVICE STATION Exr. 462.1617 HOME or MAILING ADDRESS 6747 6747 Sierra Court, Suite J S j OWNER / OPERATOR CITY Dublin STATE CA BP West Coast Products LLC DATE: CHECK if BILLINGADDRESS� FACILITY NAME ARCO 5450 SERVICE CODE: i PIE: -Z -:;O -g Fee Amount:} , O j SITE ADDRESS 1617 W FREMONT/1-5 Payment Type t((� STOCKTON 95203 Street Number Direction Street Name Ci Code HOME or MAILING ADDRESS (if Different from Site Address) 6747 6747 Sierra Court, Suite J street Number Street NaMe CITY STATE ZIP Dublin CA 94566 PHONE#1 Ext. APN # LAND USE APPLICATION # ( 209 ) 462.1617 ( ?a a j PHONE #2 Ext. BOS DISTRICT LOCATIONS CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR LIDDYMCKENZIE CHECKIfBILLING ADORES S© BUSINESS NAMEPHONE# Gettler Ryan Inc. 249 Exr. 462.1617 HOME or MAILING ADDRESS 6747 6747 Sierra Court, Suite J FAX # ( 209) 551-7888 CITY Dublin STATE CA ZIP 94568 BILKING 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 form. 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 F> RAL laws, APPLICANT'S SIGNATURE: DATE: 6/11/2013 PROPERTY/ BUSINESS OWNER❑ VPERATOR / NjA# GER ❑ OTHER AUTHORIZED AGENT Wf Agent for Owner IfAPPLICANT is not the .BILLING PARTY proof of authorization 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 environmental/site 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: UST RETROFIT COMMENTS: REPLACE SENSOR ON 91 TURBINE SUMP �. 1J ACCEPTED BY: L EMPLOYEE #:r t DATE: b z l c ASSIGNEOTO: EMPLOYEE 2 DATE: Date Service Completed (if alleady completed): SERVICE CODE: i PIE: -Z -:;O -g Fee Amount:} , O j Amount Pai&V3 �5 &VPayment Date Payment Type t((� Invoice # Check # �j2� 9 35" Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003