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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property\ FACILITY ID# ��ec <br /> Gas Station <br /> Owner/Operator [xl <br /> BP West Coast Products,LLC Check if Billing Address <br /> Facility Name <br /> ARCO 6080 <br /> Site Address 85 E Louise Ave Lathrop 95330 <br /> Street Number Direction Street Name City Zip Code <br /> Home or Mailing Address(If Different from Site Address) 4 Center Pointe Dr <br /> Street Number Street Name <br /> City State Zip <br /> La Palma CA 90623 <br /> Phone#1 Ext. APN# Land Use Application# <br /> (209) 983-9140 (site) <br /> Phone#2 Ext. BOS District Location Cede <br /> (209)649-3335 (BP) -7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Requestor Check if BILLING ADDRESS [ ] <br /> Lori Freshour <br /> Business Name Phone# Ext. <br /> Tait Environmental Systems (916) 858-1090 <br /> Home or Mailing Address FAX# <br /> 3283 Luyung Dr (916) 858-1011 <br /> City State Zip <br /> Rancho Cordova CA 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: Date: 10/6/03 <br /> L <br /> PROPERTY OWNER/BUSINESS OWNER[ ] OPERATOR/MANAGER[ ] OTHER AUTHORIZED AGENT [X] Compliance Mar. <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. -'AY M L[` i <br /> Type of Service Requested: Repair 1 <br /> i�. <br /> Comments: <br /> Replaced existing 87 LD 2000 Leak Detector with new 87 LD 2000 Leak Detector ;AN JOAQUIN COUNTY <br /> p 9 PUBLIC HEALTH SERVICES <br /> NVIRONMFNTAI HEALTH DIVISION <br /> Approved by: V s.�a.=���C� Employee#: ! �='� Date: <br /> Assigned to: �J +,.a Employee#: Date: <br /> Date Service Completed(If already completed) Service Code: P/E: C` <br /> Fee Amount: '�-\`"�� Amount Paid !_'t'�� Payment Date: <br /> Payment Type Invoice# Check# �= > Received By: <br /> EHD 48-01-025 ��_� ////���� <br /> REVISED 6-5-02 SERVICE REQUEST FORM O/%> <br />