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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH-bEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# n�SERVICE REQUEST# <br /> Gasoline Retail Fueling Facility SJIL/l�tp3��J <br /> OWNER I OPERATOR <br /> Pacific West Petroleum Inc. "' CHECK If BILLING ADDRESS <br /> FAcRITYNAME Arco AM/PM <br /> SITE ADDRESS 5,50SEC of West Valpico Rd Tracy 95376 <br /> SVeet Number Direcnon Street Name c' ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3400 Willow Pass Road <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Concord CA 94519 <br /> PHONE#I Ea. APN# LAND USE APPLICATION# <br /> (925 ) 689-0557 248-020-21 <br /> PHONER Ea. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR�-� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAM i�^+ PHO�E# * - ISv O Ea. <br /> N +� J <br /> HOME or MAILING ADDRESS FAX# <br /> w'E <br /> CITY I41(J C-"O 1A STT ZIP 4cZ <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this applicau and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an E L laws. <br /> APPLICANT'S SIGNATURTe DATE: <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANA ER 13 OTHER AUTHORIZED AGENT 11 <br /> IrAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. alil <br /> A <br /> TYPE OF SERVICE REQUESTED: V ST Awt,/J Y/y7 PIVEO <br /> COMMENTS: <br /> yr+TMRO„ ei 1 <br /> tom' <br /> ACCEPTED BY: EMPLOYEE#: Q0 DATE: 2g l/ <br /> ASSIGNED TO: 1 EMPLOYEE#: l DATE <br /> Date Service dompleted (if already completed): SERVICE CODE: Q PIE: 12303 <br /> Fee Amount: Amount Paid 1M 1 7 b [)-0 Payment Date ( ( 1 <br /> Payment Type Invoice# ( 97 Check# (]lL3 Received By: -7011- <br /> EHD 4"2-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />