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9255517888 Line 1 40 108a.m. 11-19-2009 3/15 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # SERVICE STATION CHECK If BILLING ADDRESS BUSINESS NAME Gettler Ryan Inc. e 9 ,� -7 e -j �> OWNER / OPERATOR 551-7555 Exr. BP West Coast Products LLC CHECK If BILLING ADDRESS FACILITY NAME ARCO 5450 HEW -T" pEPAHR�ENl SITEADDRESS 1617 W I FREMONT ST I DATE: STOCKTON 95203 Street Number Direction Street Name city Zip Cade HOME Or MAILING ADDRESS (If Different from Site Address) 6747 PIE: p 6747 Sierra Court, Suite J Amount Paid Street Number Street Name CITY STATE ZIP Dublin CA 94568 PHONE #1 ExT• APN # LAND /ISE APPLICATION # ( 925 } 551-7555 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQuESTOR wili\/ E D LIDDY MCKENZIE tjov 1 J CHECK If BILLING ADDRESS BUSINESS NAME Gettler Ryan Inc. PHONE # 551-7555 Exr. SAENORONME� ALS 925 HEW -T" pEPAHR�ENl HOME or MAILING ADDRESS FAX# DATE: 6747 6747 Sierra Court, Suite J ( 925 ) 551-7888 CITY Dublin STATE CA Zip 94568 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 form. I also certify that I have prepared this application and that the rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL APPLICANT'S SIGNATURE: DATE: O PROPERTY/ BUSINESS OWNER ❑ OPERAT04AANAGFIR ❑ OTHER AUTHORIZED AGENT Cid' Agent or O ner IfAPPLICANT is not the BILLING PARTY. proof of authorization t0 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. _ , r- w I r TYPE OF SERVICE REQUESTED: UST RETROFIT wili\/ E D COMMENTS: tjov 1 J REPLACE STRAIGHT DROP -TUBE (P/N 61T-7468) ON #6 WEST 87 TANK. SAENORONME� ALS HEW -T" pEPAHR�ENl ACCEPTED BY: EMPLOYEE #: / DATE: ASSIGNED TO: EMPLOYEE#: 3 DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: p Fee Amount: r Amount Paid 4 3 YS O C7 Payment Date LI 1 j9c? Payment Type ✓ L) A Invoice # Check # Received By: EHD 48-02-025 r 1 -4 3431 P SR FORM (Golden Rod) REVISED 11/17/2003