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SAN JOAQUIN•UNTY ENVIRONMENTAL HEALTH DIORTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station ZAMOS� �z1S 3 <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Arco 9600 <br /> SITE ADDRESS 1250 N Wilson Way Stockton 95202 <br /> Street Number i d n Street Name CZip Code <br /> HOME or MAILING ADDRESS (If Differentfrom Site Address) <br /> PO Box 6038 Street Number Street N.M. <br /> CITY Artesia STATE Ca. ZIP 90702-6233 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (209) 466-6633 <br /> PHONE#2 EXr. SOS DISTRICT LOCATION CODE <br /> ( 800 ) 525-5857 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Jim Cortez CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# Ear. <br /> Charles E. Thomas Co. 310 323 - 6730 259 <br /> HOME Or MAILING ADDRESS Fax# <br /> 13701 S. Alma Avenue <br /> ( 310) 715 - 8626 <br /> CITY Gardena STATE Ca. ZIP 90249 <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,STAT d FED L I s. e� <br /> APPLICANT'S SIGNATURE: /4+t DATE: 1Z 1/ k <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGE OTHER AUTHORIZED A-1� ermitTechnician <br /> If APPLicANTisnotthe BILLINGPARTY. ofo,faNthOrlgtflon r0 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 SERVICE REQUESTED: <br /> COMMENTS: <br /> DEC 1 9 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: / I <br /> ASSIGNED TO: EMPLOYEE#: d DATE: �Z �( <br /> Date Service Completed (N already completed): SERWCECODE: PIE: <br /> Fee Amount: u' Amount Paid Payment Date (-41 (GS <br /> Payment Type Invoice# Check# �(�L f(� Received By: 2ef <br /> . <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />