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SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH DORTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station 5.0t, Lf S-J <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Arco 2133 <br /> SITE ADDRESS 2908 Benjamin Holt Dr. Stockton 95207 <br /> Street Number I Direction I Street Name city Zio 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#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 21 <br /> BUSINESS NAME PHONE 11 EXT. <br /> Charles E. Thomas Co. 310 323 - 6730 259 <br /> HOME or MAILING ADDRESS FAx# <br /> 13701 S. Alma Avenue ( 310) 715 - 8626 <br /> CITY Gardena STATE Ca. 71 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,S TE and F DE laws. G� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MA G ❑ OTHER AUTHORIZEDAGENTQPermit Technician <br /> If APPLICANT is not the BILLING PARTY roof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at tOe <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 itis <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> DEC 1 9 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q VIE: <br /> Fee Amount: J' Amount Paid �-7`j. Payment Date 11�( `I S <br /> Payment Type L/ Invoice# Check# ` 1,4 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />