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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE RED/QUEST # <br /> BP Arco AM/PM ,Cco 17g5 5 <br /> OWNER/ OPERATOR <br /> BP Products North America Inc. <br /> CHECK If BILLINGADDRESS� <br /> FACILITY NAME <br /> BP Arco AM/PM <br /> SITE ADDRESS 9036 Thornton Road Stockton, CA 95209 <br /> Street Number Dirertlorn street Name Cites I Zin 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# LAND USE APPLICATION# <br /> ( 661 )250-9300 for this project 07241043 <br /> PHONE#2 ExT• BOS DISTRICT LOCATI CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> A & S Engineering/Robert Velasco <br /> BUSINESS NAME PHONE# E T• <br /> A & S Engineering <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 propert r business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific 2ENVIRONMENTAL LTH DEPARTMENT hourly Charges associated with this project Or <br /> activity will be billed to me or my business as idenI also certify that I have prepared this application rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and F <br /> APPLICANT'S SIGNATURE: DATE: 1/29/2024 <br /> PROPERTY/BUSINESS OWNER ❑ OP AER ❑ OTHER AUTHORIZED AGENT jZ Agent <br /> If APPLICANT IS not file BILLING PAR proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATI 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,rp�QVided to me or <br /> my representative. rA <br /> TYPE OF SERVICE REQUESTED: 1 CF <br /> COMMENTS: � <br /> /' 9 <br /> NF NlR Q0IN �O?� <br /> q�T ON Coo <br /> N EPq FNTq NT 1' <br /> D <br /> RTMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: r 2 <br /> ASSIGNED TO: WO <br /> /��/ EMPLOYEE#: DATE: 3 2� <br /> Date Service Completed (if already Completed): w� SERVICE CODE: 0% P I E: � <br /> Fee Amount: 240 Amount Paid 3 ztj�.�? Payment Date 2 <br /> Payment Type �- Invoice # 6heck # ' Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />