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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> JrXArco AM / PM - BP Fuel Dispensing Facility /-100 3 72 7 <br /> OWNER / OPERATOR CHECK if BILLINGAE) DRESSO <br /> t, <br /> BP Products North America Inc . <br /> FACILITY NAME <br /> Arco AM / PM - BP 2093 <br /> SITEADDRESS 3425 Tracy Blvd . Tracy , CA 95376 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 30 S Wacker Dr, 8S -363 , <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Chicago IL 60606 <br /> PHONE #1 EXT, APN # LANE) USE APPLICATION # <br /> ( 661 ) 250-9300 for this project 214108820 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> A & S Engineering / Robert Velasco CHECK if BILLING ADDRESS <br /> /g <br /> BUSINESS NAME PHONE # EXT. <br /> A & S Engineering ( 6A1 ) 25Qm9300 <br /> HOME or MAILING ADDRESS FAX # <br /> 28405 Sand Canyon Road , Suite "B" ( 661 ) 250-9333 <br /> CITY STATE ZIP <br /> Canyon Country CA 91387 <br /> BILLING ACKNOWLEDGEMENT : I , thjFEAL <br /> pr rty or business owner, operator or authorized agent of same , <br /> acknowledge that all site and/or project speE L HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed tome or my business aform . <br /> also certify that I have prepared this applicthe work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATEaws . <br /> APPLICANT' S SIGNATURE : DATE : 1 / 16/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERA R / MANAGER ❑ OTHER AUTHORIZED AGENT 0 Agent <br /> If APPLICANT is not the BILLIVX PARTY. proof of authorization to sign is required Trete <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 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 re O <br /> roer <br /> my representative , •/t`7 <br /> TYPE OF SERVICE REQUESTED : e <br /> COMMENTS : $qNJ � 2022 <br /> HEACTNp�pqF/jO ANT <br /> RTMENT <br /> ACCEPTED BY: I\vJ �rt� EMPLOYEE #: DATE: ZZ <br /> � 3 <br /> ASSIGNED TO : / !/r) ay� AD <br /> � EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed ) : SERVICE CODE:/�� Z �j': ' PIE :/� ,W . <br /> Fee Amount : e� Amount Paid Payment Date 7 2 22 <br /> Payment Type Invoice # 5ec r 3y� ��� 2 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />