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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTAI)EPARTMENT <br /> SERVICE REQUEST BCE 13448 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ARCO Retail Gasoline Facility ie 06 542- `rt;t, <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACILITY NAME <br /> ARCO Facility No. 5450 <br /> SITE ADDRESS 1617 West Fremont Stockton 95203 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P. 0. Box 5015 Street Number Street Name <br /> CITY STATE ZIP <br /> Buena Park CA 90622 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 510) 432-8397 135-110-15 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> BP West Coast Products CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> ARCO 510 432-8397 <br /> HOME or MAILING ADDRESS FAX <br /> AA(-1�`X�#f c <br /> P.O. Box 5015 'J ) 2 ' <br /> CITY STATE ZIP <br /> Buena Park CA 90622 <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> M. Alexia Inlgues Project Planne /Barghausen <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> Mneniti nq F.n9i naPrc. Tnr <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization to sign is required (see attached) Title <br /> AUTHORIZATION 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. FINYIMENT <br /> TYPE OF SERVICE REQUESTED: Lk-1� T 62 I 2 a'F (-F BECEIVED <br /> COMMENTS: <br /> MAY 1 5 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: rV I v ( V�i EMPLOYEE#: DATE: lS j 0 <br /> ASSIGNED TO: V t_>lV =L EMPLOYEE#: �' I'] DATE: ( /S <br /> Date Service Completed (if already completed): SERVICE CODE:// , P/E: .Z So, <br /> Fee Amount: C Amount Paid Payment Date 1 5 <br /> Payment Type ✓ Invoice# Check# if?(-3. Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) /) / <br /> REVISED 11/17/2003 <br />