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SAN JOAQUIT WNTY ENVIRONMENTAL HEALTH *RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME Arco 6020 <br /> SITE ADDRESS 1711 Yosemite Manteca 95336 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 6038 Street Number Street Name <br /> CITY Artesia STATE Ca. ZIP 90702-6233 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 466-6633 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 800 ) 525-5857 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jim Cortez CHECK if BILLING ADDRESS <br /> BUSINESS NAME Charles E. Thomas Co. PHONE# E <br /> 310 323 - 6730 <br /> 23 - 6730 259 <br /> HOME Or MAILJNG ADDRESS 13701 S. Alma Avenue (310) 715 - 8626 <br /> CITY Gardena STATE Ca. z,P 90249 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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,S ATE and EDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: /2Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA F.R ❑ OTHER AUTHORIZEDAGENTQ Permit Technician <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 available and at the same time it is <br /> provided to me or my representative. pay�AENT <br /> TYPE OF SERVICE REQUESTED: LSE RECEIV ED <br /> COMMENTS: <br /> DEC 19 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ./ <br /> ASSIGNED TO: EMPLOYEE#: O DATE: ( J� <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: O <br /> Fee Amount: Amount Paid -C-2-7 / o 0 Payment Date O <br /> Payment Type ,/• Invoice# Check# ! Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />