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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # -7 SERVICE REQUEST # Retail Fuel Dispensing Facility � ��0�-2 � / �� 00 OWNER / OPERATOR CHECK ifBILLING ADDRESS BP Products North America Inc . FACILITY NAME BP / ARCO Site #7147 SITE ADDRESS 1206 East March Lane Stockton , CA 95210 Street Number Direction Street Name City ZiD Code HOME or MAILING ADDRESS ( If Different from Site Address) 1206 East March Lane Street Number Street Name CITY STATE ZIP Stockton , CA 95210 PAVA PHONE #1 EXT. APN # LAND USE APPLICATION 4 �/� 17" ( 661 ) 250-9300 1, VEp PHONE #2 EXT, BOS DISTRICT LOCATION ( 661 ) 250-9300 9 Z��o QU/N CONTRACTOR / SERVICE REQUESTOR H �N �IRON c�A NTy REQUESTOR CHECK if BILLING ADDRESS CE CE Thomas Company Inc. BUSINESS NAME PHONE # EXT, CE Thomas Company Inc. 310 323-6730 HOME or MAILING ADDRESS FAX # 13701 Alma Avenue ( ) CITY STATE ZIP Gardena CA 90249 BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form , also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, TATE and FED AL laws. APPLICANT' S SIGNATURE : DATE : 12/ 17/2020 PROPERTY i BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provided t0 me Or my representative . TYPE OF SERVICE REQUESTED : COMMENTS: For existing fuel dispensers / udc' s 7/8 & 9 / 10 - Remove existing conduits , patch existing electrical penetration within the existing fiberglass udc . Install 2 new , W penetration fittings . Conduct an SB989 test . ACCEPTED BY : J � - EMPLOYEE # : DATE : ASSIGNED TO : f /S7r EMPLOYEE # : DATE : � M W:2 a U Date Service Completed ( if already completed ) : SERVICE CODE :ML / O P I E : BOO Fee Amount : fit' Amount Pa �� b � Payment Date z 2D u Payment Type 6,�A, Invoice # Check # 11 a 2(oT LEw> Received y : EHD 48-02-025 SR FORM (Golden Rod ) 07/ 17/08