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SAN JOAQUI 'OUNTY ENVIRONMENTAL HEALTHARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station a skoa L7*j-a� <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Arco 6313 <br /> SITE ADDRESS 1100SMain Street Manteca 95337 <br /> Street Number Direction Street Name citv Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 6038 Street Number Street Name <br /> C11Y Artesia STATE Ca. 'P 90702-6233 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (209) 466-6633 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 800 ) 525-5857 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jim Cortez CHECK if BILLING ADDRESS D <br /> BUSINESS NAME Charles E. Thomas Co. PHONE# EXT. <br /> 310 323 - 6730 259 <br /> HOME or MAILING ADDRESS FAX# <br /> 13701 S. Alma Avenue ( 310) 715 - 8626 <br /> CITY Gardena STATE Ca. zP 90249 <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,STA and F E laws. <br /> APPLICANT'S SIGNATURE: PATE; -14/5 <br /> PROPERTY/BUSINESS OWNER❑ O RATOR/M . AGER ❑ OTHER AUTHORIZED.AGENTQ Permit Technician <br /> If,4PPLICANT 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/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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: R <br /> COMMENTS: DEC 19 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: O DATE: /� / <br /> Date Service Completed (if already completed): SERVICE CODE: �' 1 P 1 E: <br /> Fee Amount: tag Amount Paid :A,�1-7 47 (7 0 Payment Date C�S <br /> Payment Type Invoice# Check# (a D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />