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SAN JOAQU ,BOUNTY ENVIRONMENTAL HEALTH PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if Ell LLINGADDRESS E SERVICE REQUEST # Gas Station tr)v 6� EXT. 323-6730 259 HOME or MAILING ADDRESS 13701 S. Alma Avenue OWNER / OPERATOR 715-8626 CITY Gardena STATE Ca. BP West Coast Products LLC CHECK If BILLING ADDRESS FACILITY NAME Arco 2186 EMPLOYEE #: --7A-I SITE ADDRESS 3212 N California Stockton 95204 Street Number Direction SERVICE CODE: ( Street Name city Fee Amount: Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Payment Date C — Payment Type Invoice # Check #`k -D PO Box 6038 Street Number Street Name CITY Artesia STATE Ca. ZIP 90702-6233 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 466-6633 HONE#2 EXT. ff800) 525-5857 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Jim Cortez / CHECK if Ell LLINGADDRESS E BUSINESS NAME Charles E. Thomas Co. PHONE# 310 EXT. 323-6730 259 HOME or MAILING ADDRESS 13701 S. Alma Avenue OAOUIN NTUN-N SA PL FAX# ( 310) 715-8626 CITY Gardena STATE Ca. zP 90249 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, TZZIL laws. /(� APPLICANT'S SIGNATURE: �lL DATE: ` V PROPERTY/ BUSINESS OWNER❑ OPERATOR/ AGER ❑ OTHER AUTHORIZEDAGENTQ Permit Technician If APPLICANT is not the BILLING P proof of authorization to sign is required ri Ne AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. T TYPE OF SERVICE REQUESTED: / ECEIV E COMMENTS: DEC 1 9 2005 OAOUIN NTUN-N SA PL EN'JIRONME TMENT pEPAA HEp�To BY: EMPLOYEE #: --7A-I S -ASSACCEPTED DATE: (iL/(?/S- ASSIGNED IGNED TO: �� EMPLOYEE #: 0 DATE: (7/1 -fs Date Service Completed (if already Completed): SERVICE CODE: ( PIE: 23 Qd Fee Amount: Amount Paid 7 7 v Payment Date C — Payment Type Invoice # Check #`k -D Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003