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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # / SERVICE 1,R`EEQUE`SSTT # <br /> Retail Fuel Facility In �' C, J IGJ i✓IL— lV l �J <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS / <br /> BP West Coast Products, LLC <br /> FACILITY NAME <br /> ARCO am/pm Fuel Facility FAC #7049 <br /> SITE ADDRESS 800 E Kettleman Lane Lodi 95240 <br /> Sireel Number Oirectlon Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> P.O . BOX 6038 Street Number Street Name <br /> CITY STATE ZIP <br /> Artesia CA 90702 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 415 1 902.5089 062.060.420.000 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> BUSINESS NAME PHONE # EXT. <br /> Town & Country Contractors, Inc. 916 636.9500 <br /> HOME or MAILING ADDRESS FAX # <br /> 3206 Luyunq Drive ( ) <br /> CITY Rancho Cordova, CA 95742 STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1 , 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 or <br /> 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 /> Q Daryl Lee, Retail Compliance Coordinator <br /> APPLICANT' S SIGNATURE : r l/ �-� BP West Coast Products, LLC DATE : <br /> ''1'I � I� <br /> PROPERTY I BUSINESS OWNER 00 OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at th Sa 'We it is provided to me or 3" <br /> my representative . L <br /> TYPE OF SERVICE REQUESTED : nt, >, v <br /> COMMENTS: APR 2 5 2019 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> ACCEPTED BY: a 1/1 C) EMPLOYEE # : C-(, ,�pl in DATE : <br /> ASSIGNED TO : 1 `j I L } / EMPLOYEE M �l��L/CJ� DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE ; 03 PIE : <br /> Fee Amount : Amount Paid SZ , d0 1 Y111 <br /> Payment Date u <br /> Payment Type G1 Invoice # Check # �$(p$� Rec ved y : <br /> EHD 48. 02-025 PA YMj'IV T SR FORM (Golden Rod ) <br /> 07/ 17/08 CeIV ' D <br /> APR 2 6 2019 <br /> 8AN JOAQUIN COU7Y <br /> HCH Dl;ARTM N <br />