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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTh DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property\ FACILITY ID# Service Request# <br /> Gas Station AC0075 71 <br /> Owner/Operator <br /> [X] <br /> BP West Coast Products, LLC Check if Billing Address <br /> Facility Name <br /> ARCO 6335 <br /> Site Address 4855 State Hwy 99 Stockton 95208 <br /> Street Number Direction Street Name City Zip Code <br /> Home or Mailing Address(If Different from Site Address) 4 CenterPointe Dr <br /> Street Number I street Name <br /> City La Palma State CA zip 90623 <br /> Phone#1 Ect. APN# Land Use Application# <br /> (209) 649-3335 <br /> Phone#2 Ext. BOS District Location 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 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,ESTATE andel FEDERAL laws. <br /> APPLICANT'S SIGNATURE:�/�A} r Q x�D �9 G[.l Date:��/(} <br /> PROPERTY OWNER/BUSINESS OWNER[ ] OPERATOR/MANAGER[ ] OTHER AUTHORIZED AGENT [X] Compliance Mer <br /> If applicant is not the BILLING PARTYproof of authorization to sign is required. Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located a the <br /> Above site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/si� 1114`, <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and S@C56e it is <br /> provided to me or my representative. <br /> Type of Service Requested: Repair/Retrofit <br /> Sol I pUIN COUNM <br /> T' <br /> Comments: Replace Existing Drop Tube(OPW 61SO-410C-EVR) In 87(20k tank)with new OPW 61S0 c <br /> TEPAMEtJT <br /> EVR Drop Tube <br /> Approved by:.k Employee#: (0 311 —7 Date: <br /> Assigned to: Employee* lgslicfDate: <br /> Date Service Completed(If already completed) Service Code: P/E: 21 cY <br /> Fee Amount: -71 .&b I Amount Paid e-/_0 Payment Date: [[I S t —a <br /> Payment Type Invoice# I Check# Received By: 2wl. <br /> EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FORM <br />