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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Arco AM / PM - BP Fuel Dispensing Facility 5800815 41 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Attn . Mr. Kenneth Wold / Owner <br /> FACILITY NAME <br /> Arco AM / PM - BP <br /> SITE ADDRESS 2510 South State Highway 99 West San Joaquin Count 95205 <br /> Street Number Direction I Street Name City ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2626 Cobble Rock Way <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> EI Dorado Hills CA 95762 <br /> PHONE #1 EXT' APN # LAND USE APPLICATION # <br /> 12811995-5679 171 -300- 17 ,21 ,22 <br /> PHONE #2 EXT. BOB DISTRICTLOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> A & S Engineering/Robert Velasco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # Ear. <br /> A & S Engineering _ <br /> HOME or MAILING ADDRESS FA% # <br /> 28405 Sand Canyon Road , Suite "B" ( 661 ) 250-9333 <br /> CITY STATE ZIP <br /> Canyon Country CA 91387 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property r business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/Or project Specific ENVIRONMENTAL ALTH DEPARTMENT hourly charges associated with this project Or <br /> activity will be billed to me or my business as identified on thwor <br /> I also certify that I have prepared this application and that tk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL 00 <br /> APPLICANT'S SIGNATURE: DATE: 12/13/2019 <br /> PROPERTY / BUSINESS OWNER 11OPERATOR / XTAGER [3OTHER AUTHORIZED AGENT O Agent <br /> If APPLICANT IS not the BILLINGP Tv proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMAT N: 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time It IS pfOj� tp_ rlla or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> �f�CAQU/N <br /> M NV/RO COU <br /> - .. �t[Ty�f <br /> ACCEPTED BY: EMPLOYEE M / � DATE: <br /> ASSIGNED TO: \/ EMPLOYEE #: / / DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: Q3 <br /> Fee Amount: 0j 0G+-0 . C' O Amount Paid 3 D Payment Date <br /> Payment Type GJ AInvoice # Check R ceiv d By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />