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SAN JOAQUIN0OUNTY ENVIRONMENTAL HEALTITDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property\ FACILITY ID# r� �� <br /> Gas Station Gl/J`Y'1 <br /> Al��- J <br /> Owner/Operator <br /> [ I <br /> BP West Coast Products, LLC Check if Billing Address <br /> Facility Name <br /> ARCO 9600 <br /> Site Address 1250 N Wilson Way Stockton 95202 <br /> Street Number Direction Street Name City Zip Code <br /> Home or Mailing Address(If Different from Site Address) 4 Center Pointe Dr <br /> Street Number Street Name <br /> City La Palma State CA Zip 90623 <br /> Phone#1 Site Ext. APN# Land Use Application# <br /> (209) 465-5359 <br /> Phone#2 BP Ext BOS District Location Code <br /> (209)649-3335 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Requestor Lon 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: 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 /> 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: Date: �11Z-31a 3 <br /> PROPERTY OWNER/BUSINESS OWNER[ ] OPERATOR/MANAGER[ ] OTHER AUTHORIZED AGENT [X] Compliance Mei <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 at the <br /> Above site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site asses nt <br /> Information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabl ( g time it is <br /> provided to me or my representative. <br /> Type of Service Requested: Retrofit 5 2003 <br /> ppR 2 <br /> Comments: Replaced as follows: 1 drop tube(OPW 60so 410C-EVR) In the 89 Product SAN JOAOUW G <br /> 3 VMI LD 2000 Leak Detectors in the 87,89,92 Products pUBLIC HEGN <br /> ALTH SERNp\ SI <br /> ENVIRONMENTAL HEALTH <br /> Approved by: Employee#: Date: <br /> Assigned to: Employee#: Date: <br /> Date Servioe nompleted(If already completed) Service Code: P/E: <br /> Fee Amount: Amount Paid V) Payment Date: Lf <br /> Payment Type Invoice# Check# /,j,] Received By: <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />