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SAN JOAQUtI, I-:OUNTY ENVIRONMENTAL HEALTH,ter PARTMENT BCE#13438 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ARCO Retail Gasoline Facility 73 SC s <br /> OWNER/OPERATOR <br /> BP West Coast Products, LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ARCO (Fac. No. 2186) <br /> SITE ADDRESS 3212 N California Stockton 95202 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 5015 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Buena Park CA 90622 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 510) 432-8397 <br /> PHONE#2 EXT. BOS DISTRICT PCATIO CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> BP West Coast Products `.��t "l —7--,,,1 C�"�t �S CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# 2k5 I`(p22 LExT. <br /> ARCO 510 432-8397 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 5015 ( ) <br /> CITY STATE ZIP <br /> Buena Park CA 90622 <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: DATE: D-7 <br /> PROPERTY/BUSINESS OWNER OPERATOR/NL4NAGER ❑ OTHER AUTHORIZED AGENT❑ Environmental Compliance Specialist <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 property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sI ��`3essment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ar�0.�l lie it is <br /> provided to me or my representative. F^^GE <br /> TYPE OF SERVICE REQUESTED: PERMIT MAILING DIRECTIONS <br /> COMMENTS: COVNN <br /> Once the Permit is approved the Permit and stamped NJpAQUtNfpL <br /> "approved" plans should be sent to Barghausen Consulting Engineers, IncS"E&IVA <br /> 18215 72nd Avenue South, Kent, WA 98032. Please contact Alexia Inigues at 425-251-6222. <br /> ACCEPTED BY: -1 L t v t EMPLOYEE#: 3 2 i DATE: <br /> ASSIGNED TO: A C r—LLS EMPLOYEE#: ( � �, DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ! P/E: 3 O <br /> Fee Amount: 31 -5- C Amount Paid 3 1 5db Payment Date ?filI d <br /> Payment Type l S Invoice# Check# b WO O 3 - RAC14 Received By: <br /> EHD 48-02-025 22 °o / SR FORM(Golden Rod) <br /> REVISED 11/17/2003 03 <br /> \ �✓ <br />