Laserfiche WebLink
SAN JOAQUIN %.OUNTY ENVIRONMENTAL HEALTi 1 DEPARTMENT <br />SERVICE REOUEST <br />Type of Business or Property\ <br />FACILITY ID# <br />Service Request # <br />Gas Station <br />FA -000 &77-1-3 <br />S k00 35C, 9 J <br />Owner / Operator [ X ] <br />BP West Coast Products, LLC Check if Billing Address <br />Facility Name <br />ARCO 2186 <br />Site Address 3212 <br />N <br />California <br />Stockton <br />95204 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />Home or Mailing Address (If Different from Site Address) 4 <br />CenterPointe Or <br />Street Number <br />Street Name <br />City La Palma State CA zip 90623 <br />Phone #1 Ext. <br />APN # <br />Land Use Application # <br />( 209 ) 649-3335 <br />Phone #2 Ext. <br />BOS District <br />Location Code <br />CONTRACTOR / SERVICE REOUESTOR <br />Requestor Lori Freshour <br />Check if BILLING ADDRESS [ ] <br />Business Name Tait Environmental Systems <br />Phone # Ext. <br />( 916 ) 858-1090 <br />Home or Mailing Address 3283 Luyung Dr <br />FAX # <br />( 916) 858-1011 <br />city Rancho Cordova <br />State CA zip 95742 <br />131LL1N0 ACKNU W LED(jEMEN'1': 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: October 15, 2003 <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. Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propertyc -� <br />Above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site a �J <br />Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at meY s <br />provided to me or my representative. --- a,, n nnn, <br />Type of Service Requested: Repair / Retrofit <br />SAN JOAOUIN COUNTY <br />Comments: Replaced 3 Existing Drop Tubes (OPW 61SO-410C-EVR) lo -&7 (,20k3 -an 87 (10K) tanks vAlt 99,*WIr HEALTH <br />OPW 61 SO -410C EVR Drop Tube during routine maintenance on October 15, 2003 Vkb <br />Approved by: OLS ��, ` Empl ee #: -�Date: d AL3 <br />Assigned to: % 3 Employee #: 3J�� Date: /V 1 w 0.3 <br />Date Service Completed (If already completed) Service Code: P/E: .2300 <br />Fee Amount: 40 t- Amount Paid --1,?- -7900 Payment Date: `'0/"/(p A3 <br />Payment Type ll� Invoice# Check # Received By: OV <br />EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FORM <br />