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SAN JOAQUIN C.UUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property\ <br />FACILITY ID#L <br />96)03 ( egoGas <br />Station <br />FAo c © j r <br />r� <br />Owner / Operator I I <br />BP West Coast Products, LLC Check if Billing Address <br />Facility Name <br />ARCO 5469 <br />Site Address 130 <br />S <br />Wilson Way <br />Stockton <br />95205 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />Home or Mailing Address (If Different from Site Address) 4 <br />Center Pointe Dr <br />Street Number <br />Street Name <br />City La Palma State CA Zip 90623 <br />Phone #1 Site Ext. <br />APN # <br />Land Use Application # <br />(209) 466-6633 <br />Phone #2 BP Ext. <br />BOS District <br />Location Code <br />(209) 649-3335 <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor Lori Freshour <br />Check if BILLING ADDRESS [ J <br />Business Name Tait Environmental Systems <br />Comments: Replaced as follows: 1 VMI LD 2000 Leak Detectors in the In the 91 Product <br />Phone # Ext. <br />( 916 ) 858-1090 <br />Home or Mailing Address 3283 Luyung Dr <br />FAX # <br />( 916 ) 858-1011 <br />City Rancho Cordova <br />State CA Zip 95742 <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: >364 ' 11,4Z C'6 C� Date: <br />PROPERTY OWNER / BUSINESS OWNER [ ] OPERATOR / MANAGER [ ] OTHER AUTHORIZED AGENT [X] Compliance Mgr <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 availabtAyJjV iWame time it is <br />provided to me or my representative. RECEIVED <br />Type of Service Requested: RetrofitAPR <br />2 5 2003 <br />Comments: Replaced as follows: 1 VMI LD 2000 Leak Detectors in the In the 91 Product <br />SAN JOAGUIN COON <br />PUBLIC HEALTH SERVICES <br />EtJVJONMENT4 HEALTH J)MI Oty <br />Approved by <br />Employee #: E7 <br />Date: Z 5 <br />Assigned to:. AEmployee <br />#: <br />Date: <br />Date Service Completed (If already completed) <br />Service Code: C <br />P/E: 23,f, <br />Fee Amount: 12 <br />1 Amount Paid 02(x") — Payment Date: <br />Z S a 3 <br />Payment Type ✓ Invoice# <br />Check # � ` j <br />Received By: �.�. <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />SERVICE REQUEST FORM <br />