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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # SERVICE STATION �/� () (�O � l/2 �7 OWNER / OPERATOR CHECK If BILLING ADDRESS ❑ BP ARCO WEST COAST PRODUCTS LLC FACILITY NAME ARCO -2093 SITE ADDRESS 3425 TRACY BLVD . TRACY 95376 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 6805 SIERRA COURT, SUITE G Street Number Street Name CITY STATE ZIP DUBLIN CA 94568 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 925 ) 551 . 7555 R� NT PHONE #2 EXT. 130S DISTRICT LOCATION CODE �D ( ) JA At CONTRACTOR / SERVICE REQUESTOR SAN Jo �ZZ REQUESTOR lvv/RMERLIN BOWEN CHECK ifBI11111NGt�d� O3 T AL BUSINESS NAME PHONE # EXT. ENT Gettler Ryan Inc. 925 551 .7555 HOME or MAILING ADDRESS FAX # 6805 SIERRA COURT, SUITE G ( 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 t work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FED laws . APPLICANT 'S SIGNATURE : DATE : PROPERTY / BUSINESS OWNER ❑ O RATOR / N ANAGER ❑ OTHER AUTHORIZED AGENT 1Z Agent for Owner If APPLICANT 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 : Drop Tube Replacement L ( S T 142e f1 -c �'j L/-- COMMENTS :COMMENTS : REMOVE EXISTING DROP TUBES AND INSTALL NEW FRANKLIN FUELS FFS-OPV OVERFILL PROTECTION VALVES IN 87 tank . ACCEPTED BY : G EMPLOYEE # : DATE : ASSIGNED TO : �ya � / �� -� EMPLOYEE # : DATE : Z /2Z Date Service Completed ( if already completed ) : SERVICE CODE : / �� _ 2l/� P I E : �� U Fee Amount: t14 v r� Amount Paid Payment Date ( Payment Type /11? Invoice # Check # l SZ Receiv d By : EHD 48-02-025 SR FORM (Golden Rod) REVISED 11 /17/2003