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SAN JOAQUAPUNTY ENVIRONMENTAL HEALTH WRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station z1 :Span -/J----1-3:3 <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Arco 2093 <br /> SITE ADDRESS 3425 N Tracy Blvd. Tracy 95376 <br /> Street Number I Directil Street Name Citv Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 6038 Street Number Street Name <br /> CITY Artesia STATE Ca. Zip 90702-6233 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (209) 466-6633 <br /> rNE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 00 ) 525-5857 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jim Cortez CHECK if BILLING ADDRESS <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. 7J 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,Standar AT d F DERAL laws. / �f <br /> APPLICANT'S SIGNATURE: //JI- DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT MANAGER ❑ OTHER AUTHORIZED AGENTZ Permit Technician <br /> If APPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: y5rRECEIVED <br /> COMMENTS: <br /> DEC 19 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: /� I Q <br /> ASSIGNED TO: EMPLOYEE#: DATE' 2 _/ <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 3 <br /> Fee Amount: w Amount Paid ���� v Payment Date <br /> Payment Type Invoice# Check# L'b�� Received By: 6-1�— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />