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May 06 03 06:06p TAIT Environmental System ( i) 858-1011 p.3 <br />SAN JOAQUIN COUNTY EINVIRO MENTAL HEATH DEPARTMENT <br />SERVICE REQUEST <br />Type ofl3ustressor?rcttartyt I'ACILITY'O* ' d 003 / ec <br />i G83 Station <br />f} Gi 9j (p / �. I ` <br />'',woe 0 ep razor <br />BP West ^,oast Products, LLC <br />E -- <br />Fac l9v Name <br />rJl1c A6dr6S5 1313 S i WilsonWay Stockton <br />SVOet tB,mOtlr OIf�Clicn atnn Name <br />Nome or Mailing Aorrns (if OiMarent from Site Addrem) 4 Center PGlnte Cr <br />s.r�et .vunow SI'Let tvome <br />Gl q La Palma State CA Zip 34623 <br />P o� no W Site <br />(209) 466-6633 <br />Phone p2 BP <br />j (20S) 849.3335 <br />F,n I APN 9 <br />Ext. <br />(;I <br />check r' f Ilona Pd�ress <br />i 95705 <br />I uC CorJc <br />i .and Use Appllc.-at•pn # <br />---moi <br />' gpg �isVi t i t cCdiir o C„ae <br />CONTRACTOR r SERVICE REQUE5TOR <br />Rea�93tor .ori Fresnvur Cnook if BILLING 4DDRESS ( ) <br />Sustresss Name Te'd[nvimnmental System: I Phone it =>R <br />i � (9t6) 868-tOSC � <br />Nome or Matting Address 3283 Luyuna Dr FAX M <br />I i;y Ranono cordon State GA Zi;, 85742 <br />R11 7 tttr ,�VC?V�LEDGEAII?NT: 1, he undersigned property or business owner, operator or authonzed agcat of wine, <br />Acknowledge that all site andror project specific ENVIRONME'TTAL HFA -TA DEPARI'MENT hourly charges associated with this project <br />or sctivtt} will be billed to me or my business as identfed cr. this form. <br />I also eerc.fy that I have prepared this application and Char the work to be performed will be done m accordance Mth all 5 kN JOnQUCN <br />COUNT)' Ordirance Code, Standards, STAT[ erd FEDEPA. <br />APPLICANT'S SIGNATURE:, .r�i1 <br />to A.ri.4 Date: <br />C � <br />Px()PC.ATY Ot+ 'I R / BvsatESS OWNER ( I QFV.FATOR , NL4,NAGER (I OTt•ICR AUT:lOFiIZED AGENT f XI .Cnp ;ianC<: A r_ <br />Icappl'canr isnot rhe BJL IL ?JG PAPTYprooj of authorization to sign sw requirod, iTuv <br />AUTHOWZATYON TO RELEASE INFoRtifATION: Whep applicable,1, the owner or aperator of the progeny ;oca:ed it the <br />Above site address, hereby 2uthori2e the telease of any and all resslts, geotechAical data andlor envitortmentaIlsite assessment <br />Infornaka to the S,�N IOAQUIN'' COU',,TY $1ti'VMOV.'k4EN-, AL HEALTH DEPARTMENT as 50011) !S it S AVaih'UaA;OMffiH1nC time it is <br />provided to me or rrry representative. <br />Hype or Servioe Requested! Reteof,l <br />Comments: Replaced ds folbns: 1 VMI LO 2000 Leek Detectors in the In the 91 Product �A^1 3C kauU N CD's <br />THSEt1J1CfS <br />� �NMRt3MtAftST/i n� OClSCta <br />Ap^ved by Emptoyce #. ( ti �( D210 f <br />A3signed to. r Employoe M. Date <br />Date Service Completed ;It alresdy oomplctedl i Se-vve Cedes ( PIE- <br />Fee Anount: 0 1 Amount Pato tb oZ b Payment Date' 11 S: [ a 3 <br />?aym0nt'ype 1% Invyicek Cneck# ��"� ReccrveoBr. <br />ENJ 48-Ct-025 <br />REVISED 6.5-02 SEt�VICF kFUUF57 FORMA <br />