Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Arco AM / PM - BP Fuel Dispensing Facility <br />FACILITY ID # <br />( 3 1 0 <br />SERVICE REQUEST # <br />tOW -71) <br />OWNER! OPERATOR CHECK if <br />BP Products North America Inc. <br />BILLING ADDRESS <br />FACILITY NAME <br />Arco AM / PM - BP 7161 <br />SITE ADDRESS 1243 <br />Street Number <br />West <br />Direction <br />March Lane <br />Street Name <br />Stockton <br />City <br />95215 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 30 <br />Street Number <br />S Wacker Dr, 8S-363, <br />Street Name <br />CITY STATE ZIP <br />Chicago IL 60606 <br />PHONE #1 ExT. <br />( 661)250-9300 for this project <br />APN# <br />108-160-10 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />A & S Engineering/Robert Velasco <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />A & S Engineering <br />PHONE # <br />l 661125D-9300 <br />EXT. <br />HOME or MAILING ADDRESS <br />28405 Sand Canyon Road, Suite "B" <br />PAX # <br />( 661)250-9333 <br />Cm, Canyon Country / <br />STATE ZIP <br />CA 91387 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned prope • or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL EALTH DEPARTMENT hourly charges associated with this project Or <br />activity will be billed to me or my business as identified on this <br />I also certify that I have prepared this application and th t work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and PEDER A; <br />APPLICANT'S SIGNATURE: <br />PROPERTY I BUSINESS OWNER El <br />If APPLICANT LS not the BILLING P <br />AUTHORIZATION TO RELEASE INFORMATI <br />DATE: 7/1/2021 <br />site address, hereby authorize the release ofp <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL <br />my representative. <br />A.GER OTHER AUTHORIZED AGENT Agent <br />1-v proof of authorization to sign is required Title <br />N: When applicable, I, the owner or operator of the property located at the above <br />ny and all results, geotechnical data and/or environmental/site assessment information <br />LTH DEPARTMENT as soon as it is available and at the same time it p461ed to me or <br />TYPE OF SERVICE REQUESTED: NR u/0 (ley\ 0-e i--1 r( .e .t c c .Q r-tyr 'IcCIL7v i ED <br />COMMENTS: <br />b JUL 1 n .e (cc-cib„,1: tic_ c.A fi-,-. ( ..7 2021 SAN Jo, : Lfr_ENviii,18(1/N <br />'1cALTH , NmEtv,,,Nry <br />ro 10.e r # V 0 e-t.S e no i n -ee r , c_cp rn LJEpAR ,t,4 L. i MEN?. <br />ACCEPTED BY: Ca_ c1Irsk-e5 C -0 EMPLOYEE #: DATE: -7 _ 11 ....2._ ( <br />ASSIGNED To: Ro v i‘c IA ,, 4-- ..._. EMPLOYEE #: DATE: 7 _tel ,.....2., ( <br />Date Service Completed (if already completed): SERVICE CODE: r.2...3 PIE: to 0 I <br />Fee Amount: Amount Paid70 956%00 Payment Date 7/17/2.1 <br />Payment Type Invoice # Check # I ws--63-3?7 ecei ed By: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08 <br />Pg09-1go