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f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT BCE#13455 <br /> L SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ARCO Retail Gasoline Facility <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> BP West Coast Products LLC <br /> FACILITY(NAME <br /> ARCO Fac . No. 6020 <br /> SITE ADDRESS 1711 East Yosemite Manteca 95336 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> P. 0. BOX 5 015 Street Number Street Name <br /> CITY STATE ZIP <br /> Buena Park CA 90622 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 510) 432-8397 208-310-12 <br /> PHONE#2 EXT. BOS DISTRICTEC A-90V CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ruth Ha CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> BP West Coast Products LLC 50 475-2982 <br /> HOME or MAILING ADDRESS FAX# <br /> P. O. Box 6038 ( ) <br /> CITY STATE ZIP <br /> Artesia CA 90702 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, opera or or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly harges 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 iaccordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT EDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: / IO <br /> Envirlonmental <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Specialist <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 asAit4f available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: lel.S T Op—= , F—cT G <br /> COMMENTS: <br /> 0 1 Of- <br /> Spa,Nv RO P a�M ANO V 12 2008 <br /> NV1- ENVIRONMENT HEALTH <br /> ACCEPTED BY: /1 C I v t fivr­ <br /> EMPLOYEE#: D3 L_/ ATE: <br /> ASSIGNED TO: N ( EMPLOYEE#: �7/J DATE: lZ ©e <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 220'? <br /> Fee Amount: !S Amount Paid ` 5 Payment Date <br /> Payment Type Invoice# Check# ` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 13455.004.pdf <br />