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1ai14i1bb3 15:�� 1fdy4bH3433 FIFTH FLOOR <br />SAN JOAQUIN A111W 33NVMONMEMAL EMALMIEIPARtMENT <br />SERiTICE ItE VEST <br />Type of Business or property) FACILITY 100 Service Request # <br />Gas Station. % ,3 <br />LI <br />Own®t /Operator , <br />BP West Coast Products, LLC <br />Facility Name <br />ARCO 6347 <br />Site Address 2430 <br />Stroet Number <br />Home or Melling Address Of Different from Sits Address) <br />aty La Palma <br />Phone #1 Ext, <br />( 200 ) 849-3336 <br />Phone 02 Ext, <br />CON <br />Requestor Lotti Freshour <br />suainess Name Tait Ernrironmental Systems <br />Home or Mailing Address 8283 Luyung Dr <br />PAGE 03 <br />[x) <br />Cheek ff EEM.!dense <br />Joe P®mbo Pkwy Tracy <br />4 - CenterPointe Dr <br />Bireet Number 1i &test Nene <br />State CA Zip 90623 <br />APN # Land Use Application 9 <br />95376 <br />Zip Code <br />I I SOS District I Location Code <br />Check if BILLING ADDRESS [ I <br />Phone # Ext <br />( 918) 853-1090 <br />FAX # <br />( 816) 868-9011 <br />state CA Zip 96742 <br />BILLING ACKNO i flUGEMENT: 1, the undersigned property or busihcw owner, operator or authorized agent of same, <br />Actmmowledge that all d* and/or project specific ENVIRONMENTAL HsALTH 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 ptrrfmmed will be done in accordance with all SAN JoAQUIN <br />COUNTY Ordinance Codes, Standards. STATS and FimwAL laws. <br />APPLICANT'S SIGNA,/�—� Date: JD <br />PRoPERTy OWNsx /Busnms OWNER [ j OPERATDR / MANAQM [ ] OTHER ALTT140JU21D AGENT 1'�]' <br />if'applicant is not the &U—Z V'G PARTYproof of aurhor/zadon to sign is required Me <br />��1TIiORIGATION TO RICI.,EASE INFORMATION: When applicable, I, the owner or operator of ft prop PWWM-e <br />Above site address, hereby authorize the release of any and all results, geotechnical sa op V data and/or environtnew <br />iufcrmation to the SAN JOAQUIN COUNTY EWrKONMENTAL HMLTH DEPARTMBNT as soon as it is available artd a Sanas rim® itis <br />provided tonne or my representative, Za <br />OVI <br />Type of Servloe Request*& Repair / Retrofit <br />_. ,., rntltdTY <br />:omments: Replaced Existing Drop Tube (OPW 61SO-4100-EVR) In 87 (20k tank) with new OPW 6� <br />=VR Drop Tube C' j�yLa r,ds <br />y 'ar'eri by Employee *: Date; <br />isslgned to: ; Employjete 1k. Date: <br />)ate service Completed (It already completed) SetvIce Coda: PTE <br />'oo Amount Amount Paid Payment Date' (0 D <br />'ayment Type ✓ invoice# Check 0 $2PU� Reoehrad <br />EHD 48-01-025 REVISED 84-02 SERVICE REQUEST FORM <br />