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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CONVIENCE STORE/ GAS STATION 1-(0:75--Ci <br />FACILITY ID # SERVICE REQUEST # <br />Z <br />OWNER! OPERATOR <br />BP/ WEST COAST PRODUCTS, LLC CHECK if BILLING ADDRESS X <br />FACILITY NAME ARCO AM/PM <br />SITE ADDRESS 2910 <br />Street Number <br />W <br />Direction <br />8 MILE ROAD <br />Street Name <br />STOCKTON <br />City <br />95209 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 30 <br />Street Number <br />S WAKER DRIVE, STE 900 <br />Street Name <br />CITY'CHICAGO STATE IL ZIP 60606 <br />PHONE #1 ExT. <br />( 281) 995-5679 <br />APN # 070-070-01 <br />LAND USE APPLICATION # <br />P16-0667 <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT <br />.,.., <br />LOCATION CODE <br />,,---, <br />—_, <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR SARA M FERRELL CHECK if BILLING ADDRESS <br />BUSINESS NAME CSHQA, INC PHONE # <br />(916 ) 527-6970 <br />ExT. <br />HOME or MAILING ADDRESS <br />1450 HARBOR BLVD, STE A <br />FAX # <br />( ) <br />CITY WEST SACRAMENTO STATE CA ZIP 95691 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: 7 /"L'AA DATE: 06-0748 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El ARCHITECT'S PROJECT MANAGER <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERXICE FSECIUF-ST,ED: 7---(y.:cit P in n itioc.Ic--- _ _, -,-.0 •n:.,- ,rr- , . „....„. <br />PAYMENT <br />, • 1--:.-.7.7,.. /7 RECEIVED <br />yftl <br />JUN 1 4 2018 <br />NVIRONMENTAL HEALTH <br />SAN JOAQUIN COUNTY PFRMIT/SERV!CES , <br />ACCEPTED BY: 4. ENVIRONMENTAL <br />EMPLOYEE #: HEALTH DEPARTMAM: &I iLi i 13 <br />— ASSIGNED TO: .I.12,sn ,ry.-.--,---.?- EMPLOYEE #: DATE: Q h Li I R7 <br />• Date Service Completed (if already completed): SERVICE CODE: ,._ .2:3 P IE: ' ; -. .1 1 <br />Fee Amount: ; Li(--/ , .(f----1 <br />_ <br />Amount Paid 4. 45-(> ,c-,,D Payment Date (.0 \k k`', <br />Payment Type Oive.A._ Invoice # Check # k 0 pu --- Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />i-'os4qo