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SAN JOAQUIOOUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station k00 &22(:)C <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Arco 5450 <br /> SITE ADDRESS 1617W Fremont Stockton 95203 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)4 FCenterpoint Drive <br /> Street Number Street Name <br /> CITY La Palma STATE Ca. ZIP 90623 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (530)621-0770 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Randy Brown CHECK If BILLING ADDRESS � <br /> BUSINESS NAME an Inc. PHONE# EXT. <br /> Gettler-R <br /> Y (925)551-7555 <br /> HOME or MAILING ADDRESS FAX# <br /> 6747 Sierra Court Suite J (925 )551-7888 <br /> CITY Dublin STATE Ca ZIP 94568 <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,Stand=ST :EDERAL law <br /> APPLICANT'S SIGNATURE: DATE: March 28, 2011 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Service Manager <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: '�A ST �� T�—C S� (T RECEIV <br /> EIJ <br /> COMMENTS: MAR 3 0 201 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: `I l/E. t EMPLOYEE#: C)3-Z_f DATE: �0 t t <br /> ASSIGNED TO: U ECi EMPLOYEE#: DATE: 3 <br /> Date Service Completed (if already completed): SERVICE CODE—: / C g P I E: C g <br /> Fee Amount: $366.00 1 <br /> Amount Paid $366.00 Payment Date March 28,2011 <br /> Payment Type Credit Card Invoice# Check# Received By: Z,- <br /> Confirmation #A630261/' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />