COMPLIANCE INFO_2003-2005 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT•DEPARTMENT SERVICE REQUEST Type of Business or Property\ FACILITY ID# Service Request # Gas Station Phone # Ext. ( 916 ) 858-1090 Home or Mailing Address 3283 Luyung Dr Owner / Operator [ x 1 BP West Coast Products, LLC Check if Billing Address Facility Name ARCO 6347 Site Address 2430 Employee #: Joe Pombo Pkwy Tracy 95376 Street Number Direction Street Name City Zip Code Home or Mailing Address (If Different from Site Address) 4 CenterPointe Dr Street Number Street Name City La Palma State CA Zip 90623 Phone #1 Ext. APN # Land Use Application # ( 209 ) 649-3335 Phone #2 Ext. BOS District Location Code CONTRACTOR / SERVICE REQUESTOR Requestor Lori Freshour Check if BILLING ADDRESS [ ] Business Name Tait Environmental Systems Phone # Ext. ( 916 ) 858-1090 Home or Mailing Address 3283 Luyung Dr Comments: Replaced Existing Drop Tube (OPW 61 SO-410C-EVR) In 87 (20k tank) with new OPW 69% C FAX # ( 916) 858-1011 City Rancho Cordova State CA zip 95742 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, Acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: J Date: v :1 °'03 PROPERTY OWNER / BUSINESS OWNER [ ] OPERATOR / MANAGER [ ] OTHER AUTHORIZED AGENT If applicant is not the BILLING PAR TYproof of authorization to sign is required. Tide AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the prop iIM@W'The Above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/si �60�ED Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a the same time it is provided to me or my representative. g1rT 20Q� Type of Service Requested: Repair / RetrofitCOUNN SAN '�H�A 1K SERNSSION nRl Comments: Replaced Existing Drop Tube (OPW 61 SO-410C-EVR) In 87 (20k tank) with new OPW 69% C EVR Drop Tube Approved by: till,( �5 �,�j Employee #: Date: C Assigned to: 6h-, Employee #: 7 `^' Date: Date Service Completed (If already completed) Service Code: P/E: ` Fee Amount: D Amount Paid Wil' _ Payment Date: Payment Type w. - Invoice# Check # 5a001> Received By: EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FORM