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SAN JOAQUIN WUNTY ENVIRONMENTAL HEAL t-, DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property\ FACILITY ID# Service Request# <br /> Gas Station P ov 3 65 0 <br /> Owner/Operator [x 1 <br /> BP West Coast Products, LLC Check if Billing Address <br /> Facility Name <br /> ARCO 4932 (N-70) <br /> Site Address 16 E Harding Way Stockton 95204 <br /> Street Number Direction Street Name City Zip Code <br /> Home or Mailing Address(If Different from Site Address) 4 CenterPointe Dr <br /> Sheet Number Street Name <br /> City La Palma State CA zip 90623 <br /> Phone#1 Ext. APN# Land Use Application# <br /> (209) 649-3335 <br /> -T Phone#2 Ext. BOS District TLocation Code <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Requestor Lori Freshour Check if BILLING ADDRESS [ ] <br /> Business Name Tait Environmental Systems Phone# Ext. <br /> (916) 858-1090 <br /> Home or Mailing Address 3283 Luyung Dr <br /> t FAX# <br /> (916) 858-1011 <br /> City Rancho Cordova State CA zip 95742 <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 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:Z/7L �Y1 /�1.1� Date: <br /> PROPERTY OWNER/BUSINESS OWNER[ ] OPERATOR/MANAGER[ ] OTHER AUTHORIZED AGENT [X] Compliance Mgr <br /> If applicant is not the BILLING PARTY proof of authorization to sign is required Time <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: Repair/ Retrofit <br /> Comments: Replaced Existing Drop Tube (OPW 61SO-410C-EVR) In 87 Master with new OPW 61SO-410C EVR <br /> Drop Tube during Vapor Recovery Testi g .\ <br /> Approved by: Employee#: q41 5(q Date: tO b 7 D <br /> Assigned to: Employee#: 7-3 Date: t0/(9-7 03 <br /> Date Service Completed(If already completed) Service Code: O d P/E: <br /> Fee Amount: Amount Paid Ql —y— — Payment Date: /'P <br /> Payment Type a Invoice# Check#50 Received By: <br /> EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FORM <br />