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I <br />Type of Business or Property FACILITY ID # <br />r <br />Direction <br />60606 <br />Ext. <br />Ext.BOS District Location Code <br />Requestor <br />Ext. <br />State CA <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />OCT 3 0 2023 <br />Vidal Pedraza 6213Accepted By:Employee #:10-26-23Date: <br />10-26-23Fracisco Ruiz 9838Assigned to:Employee #: <br />523Date Service Completed (if already completed): <br />486Fee Amount:Payment Date <br />Invoice # <br />Payment 171017951 <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />Phone # <br />( 661 ) 250-9300 <br />Fax# <br />J___ <br />Email <br />Comments: <br />Proposed Gas station with Carwash and Food mart <br />Electronic plan review. <br />SERVICE REQUEST# <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />95209 <br />Zip Code <br />30 <br />Street Number <br />Thornton, Rd <br />Street Name <br />Service Code: <br />— <br />Check # <br />City <br />Chicago_________ <br />Phone#1 <br />(661) 250-9300 <br />Stockton <br />___________City__________ <br />S. Wacker Drive <br />_________Street Name <br />Zip <br />Proposed Gas station with Carwash <br />Owner/Operator <br />BP West Coast Products LLC <br />Facility Name <br />bp ARCO <br />Site Address <br />9036__________Street Number <br />Home or Mailing Address (If Different from Site Address) <br />APN# <br />108-160-10 <br />Email <br />ajara@asengineer.com <br />CONTRACTOR / SERVICE REQUESTOR <br />State <br />IL <br />Land Use Application # <br />Phone #2 <br />(____) <br />)_____________________ <br />ajara@asengineer.com <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 or activity <br />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 />C-Jrkl L____________ Date-. 10/26/2023 <br />Property / Business Owner Operator / MANAGERyO Other Authorized Agent Q____________________________ <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 site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />San Joaquin County Environmental Health Department as soon as it is available and at the same time it is .PLOMciedtp me or my <br />representative PAY M E N T <br />RECEIVED <br />Check if Billing Address D <br />Check if Billing AddressD <br />Date: <br />|/P/E: /601 <br />( ''a <br />Received By: <br />Abigail Jara <br />Business Name <br />A&S Engineering__________________ <br />Home or Mailing Address <br />28405 Sand Canyon Rd Suite B <br />C|TY Canyon Country <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Amount Paid <br />Z|P 91387 <br />Payment Type