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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 Step, (10 9 Ll C� <br /> OWNER/OPERATOR <br /> BP Products North America Inc. <br /> cF/ECKifBILLINGADDREss❑ <br /> FACILITY NAME <br /> Arco AM/PM -BP 7161 <br /> SITE ADDRESS 1243 West March Lane Stockton 95215 <br /> Street Number Direction Street Name City. Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 30S Wacker Dr, 8S-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 108-1-60-10 <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 III EXT. <br /> A&S Engineering ( )250-9300 <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, the undersigned prop rty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENT HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this orm. <br /> also certify that I have prepared this application and tha a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERA WS. <br /> APPLICANT'S SIGNATURE: —> DATE: 7/1/2021 <br /> PROPERTY I BUSINESS OWNER❑ OPER*66Wi6lAGER ❑ OTHER AUTHORIZED AGENT 0Agent <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 the same time It IS provided to me or <br /> my representative. t <br /> TYPE OF SERVICE REQUESTED: S / s <br /> COMMENTS: � <br /> Y <br /> �"sgN'Jo 08 '?0 <br /> /yFq�TNRoNMN COC/ <br /> °FPq FNT'I Al <br /> ACCEPTED BY: III ) /g-G EMPLOYEE#: DATE: 7 <br /> ASSIGNED TO: `JAllm�l N.f� I V EMPLOYEE M DATE: -7h <br /> Date Service Completed (if already completed): ^^ SERVICE CODE: CI,al PIE: �/ Q <br /> Fee Amount: Amount Paid Payment Date/ <br /> Payment Type ,'-9 1() ,_;�.� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />