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SAN JOAQUII 7UNTY ENVIRONMENTAL HEALTH IARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station Si2-co <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS El <br /> FACILITY NAME Arco 6080 <br /> SITE ADDRESS 85 E Louise Lathrop 95330 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 6038 Street Number Street Name <br /> CITY Artesia STATE Ca. 'P 90702-6233 <br /> PHONE#I 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 <br /> BUSINESS NAME PHONE# EXT. <br /> Charles E. Thomas Co. 310 323 - 6730 259 <br /> HOME Or MAILING ADDRESS 13701 S. Alma Avenue ( 310) 715 - 8626 <br /> CITY Gardena STATE Ca. zP 90249 <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,ST nd F laws. <br /> APPLICANT'S SIGNATURE: DATE: �� 5 <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MAN R ❑ OTHER AUTHORIZEDAGENTQF(ermif Technician <br /> 1f APPL/CANT 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: DEC 19 2005 <br /> SAN JOAGUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: -FiDATE: <br /> ASSIGNED TO: EMPLOYEE#: E] DATE: T <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E:.Z3( <br /> Fee Amount: 2,11 Amount Paid � l (� Payment Date <br /> Payment Type ✓' Invoice# Check# `(o(f� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />