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IU/ <br /> our rio., curio lb:ly - <br /> 216J4b83433 FIFTH FLOOR PAGE 02 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEvARTMENT <br /> StRVICL REQUEST <br /> Type of Business or Property) FACIUTY ID# <br /> Gas Station <br /> Pa <br /> Owner/Operator <br /> Check n Bllung Address <br /> BP West Coast Products,LLC <br /> Faculty Name <br /> ARCO 6080 <br /> Site Address 85 Louise Ave Lathrop 95330 <br /> Slreal NUlil�ar Dlrecllon Street Name City zlD Code <br /> Home or Mailing Address(if Different from Site Address) 4 Center Point®Dr <br /> svw Nmmw street Nems <br /> city State Zip <br /> La PaUm CA 90623 <br /> Phone 1 Fwd. APN# Land Uee AppiloaVon# <br /> (209) 983-9140 (site) <br /> Phone#2 set. SOS Distrlot Location Code <br /> (209) 648-3335 (6P) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> Requestor Check If BILLING ADDRESS [ <br /> Lori Freshour <br /> Business Name Phone Ext. <br /> Tait Environmental Systems (916) 858-1090 <br /> Home or Mailing Mdreee FAX# <br /> 3283 Luyung Or (816) 858-1011 <br /> � State Zip <br /> City <br /> CA 95742 <br /> Rancho Mrdm <br /> BILLING A,CICNOWLEDGEMENT: I,the=dersigned property or business owner,operator or authozized agent of same, <br /> ENTAL HEA4Tti DEPARTMENT hourly charges associated with this project <br /> Acknowledge that all site and/or project specific BNVIROD(M <br /> or activity will be billed to me or my business as identified on this for <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 JOAQUTN <br /> COUNTY Ordinance Codes,standards, STATE and FED13FAL laws. <br /> APPLICANT'S SIGNATURE: Date: to/6/03 <br /> PROPERTY OWNER/BUSINESS OWNER[ ] OPERATOit/MANAGER[ ] OTHER AUTHORIZED AGENT [X] C0=1 ante Mer. <br /> If applicanr is not the BLUMPR proof of authorization to sign is required. <br /> rrle <br /> AUTgORIZATION 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 ENvIRONMENT.AL HEALTH DFPAkTMENT as soon as it is available and at the same time it is <br /> provided to me or ray representative. PAYMENT <br /> Type of Service Requested: Repair <br /> Comments; <br /> PUBLICOHEALT 1 EUIN RJI ES <br /> NTY <br /> Replaced existing 87 LD 2000 Leak Detector with new 87 LD 2006 Leak Detector , <br /> ENVIRONMENTAL HEAL1H DIVISION <br /> AppnaEmployee A .� =�`-�'�, Gate:XA <br /> ved bY• , t7er� �C.s. <br /> Assigned bt• Fmployde.#; . �Cj Date: <br /> Date'Sen4de Completed(If aiready completed) Service•,Code: <br /> Fee Amount' C13ILW ---� o <br /> Amunt Paid Poyment pate: <br /> Paymerit�Type <br /> Invoice# Check �y `. Recelved.By; <br /> EMD 4M1-026' <br /> REVISED 6.6-02 6£R1ACE REQ11E67 FORM <br />