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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 <br /> OWNER / OPERATOR CHECK IfBILLINGAODRESSO <br /> 1, <br /> BP Products North America Inc . <br /> FACILITY NAME <br /> Arco AM / PM - BP 2093 <br /> SITE ADDRESS 3425 Tracy Blvd . Tracy , CA 95376 <br /> Street Number Direction Streak Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 30 S Wacker Dr, 8 &363 , <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Chicago IL 60606 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 661 ) 250-9300 for this project 214108820 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> A & S Engineering / Robert Velasco CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> A & S Engineeringt RF _q <br /> HOME or MAILING ADDRESS FAX # <br /> 28405 Sand Canyon Road , Suite " B " ( 1561 ) 250-9333 <br /> CITY STATE ZIP <br /> Canyon Country CA 91387 <br /> BILLING ACKNOWLEDGEMENT : I , the undersigned pr rty or business owner, operator or authorized agent of same , <br /> acknowledge that all site and /or project specific ENVIRONME L HEALTH DEPARTMENT hourly Charges associated with this project Or <br /> activity will be billed to me or my business as identified on form . <br /> also certify that I have prepared this application an the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FE AL laws . <br /> APPLICANT' S SIGNATURE : DATE : 1 / 16/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERA R i MANAGER ❑ OTHER AUTHORIZED AGENT fa Agent <br /> If APPLICANT is not the BILL PAR » , proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , 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 assess t information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the Same time it IS �a Or <br /> my representative . •/`'7Lft�fy� N <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : SAN ,J � 2�2Z <br /> NEgk pp P6 y0 O 74 <br /> EA NT <br /> RTMFNT <br /> ACCEPTED BY : �\ EMPLOYEE #: DATE : 62/ <br /> z1 Z3 <br /> ASSIGNED TO : i A 14"02 enV EMPLOYEE # : DATE : 2 Z / Z � <br /> Date Service Completed (if already completed) : SERVICE CODE;/4V ZP I E ; �2Wf <br /> LL <br /> Fee Amount : Amount Paid V Payment Date 2 22 <br /> Payment Type Invoice # �Qhec�lit :" 3W U5 Z,. 1 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />