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9255517888 Line 1 :00 a.m. 04-07-2010 3/12 <br />r✓t-aa�vv['a.a�v 0-1l l—1'Al\Vl\171-'1\1111)111.'111-111 L'i1�11�'1L`lri <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />SERVICE STATION <br />PHONE # <br />925 <br />3(0 0 <br />HOME Or MAILING ADDRESS <br />6747 <br />J 100 5 %ff <br />OWNER / OPERATOR <br />551-7888 <br />CITY Dublin <br />BP West Coast Products LLC <br />LP 94568 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ARCO 5450 <br />EMPLOYEE #: <br />` <br />SITE ADDRESS 1617 <br />W <br />FREMONT ST <br />��{'� <br />DATE: <br />STOCKTON <br />95203 <br />Street Number <br />01reetion <br />Street Name <br />Amount Paid (�s®� <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 6747 <br />Payment Type (V-� <br />6747 Sierra Court, Suite J <br />Check # <br />Street Number <br />Received By: <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 />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR LIDDYMCKENZIE <br />CHECK if BILLING ADDRESS© <br />BUSINESS NAME Gettler Ryan Inc. <br />PHONE # <br />925 <br />Exr. <br />551-7555 <br />HOME Or MAILING ADDRESS <br />6747 <br />6747 Sierra Court, Suite J <br />FAX # <br />( 925 ) <br />551-7888 <br />CITY Dublin <br />STATE CA <br />LP 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 an at the rk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an DEKA ws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER❑ OP TOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IA Agent for Owner <br />VIAPPLICANT 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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: UST RETROFIT <br />N I <br />pAY ME <br />COMMENTS: <br />REPLACE SENSOR (P/N 794380-323) ON L5 AT 87 MASTER STP <br />ppR _ 1 ZO1O <br />Oo <br />Ssv <br />P's JOAOUM <br />NVIR N9%jjakw <br />HF.AI-TM <br />ACCEPTED BY: J � <br />EMPLOYEE #: <br />` <br />DATE: q / %1 <br />V <br />VL41-7 <br />ASSIGNED TO: r F.�n % <br />EMPLOYEE #: <br />��{'� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Pik: <br />Fee Amount: l) <br />Amount Paid (�s®� <br />Payment Date <br />0 <br />Payment Type (V-� <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 r� SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />