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SAN JOAQUIN ,, OUNTY ENVIRONMENTAL HEALTIh DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property\ �In MOOFACILITY ID# 9 J4 „6 R5 11 <br /> Gas Station r1 V 9Z--J4-- D6 <br /> 11 <br /> Owner/Operator 1 X I <br /> BP West Coast Products, LLC Check if Billing Address <br /> Facility Name ARCO SS#6080 <br /> Site Address 85 E Louise Ave Lathrop 95330 <br /> Sheet Number Direction Street Name City Zip Code <br /> Home or Mailing Address(If Different from Site Address) I <br /> Street Number Street Name <br /> City State Zip <br /> Phone#1 Ext. APN# Land Use Application# <br /> 209 983-9140 <br /> Phone#2 Ext. BOS District Location Code <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Requestor Lori Freshour Check if BILLING ADDRESS ( ] <br /> Business Name Tait Environmental Systems Phone# Ext. <br /> 916 858-1090 <br /> Home or Mailing Address 3283 Luyung Drive FAX# <br /> 916 858-1011 <br /> City Rancho Cordova State Zip <br /> 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 HEAL'ITi 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. l Za <br /> APPLICANT'S SIGNATURE: Date:'?ZZ5 3 <br /> PROPERTY OWNER/BUSINESS OWNER [ ] OPERATOR/MANAGER [ ] OTHER AUTHORIZED AGENT [X] Compliance Manager <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. <br /> Type of Service Requested: Retrofit/Repair <br /> Comments: Replaced Drop Tubes in 87, 89 and 91 products per 2/23/03 Vapor Recovery Testing <br /> Approved by: W Employee#: G'v� Date: r <br /> Assigned to: ` Employee#: -30 Date: I <br /> Date Service Completed(If already completed) Service Code: I q P/E: 93019 <br /> Fee Amount: 9,(e-7 Amount Paid `���� _1](� Payment Date: -2-45-/a 3 <br /> Payment Type Invoice# Check# D 1"1`] Received By: L— <br /> EHD 48-01-025 PAYMENT <br /> REVISED 6-5-02 RECEIVED SERVICE REQUEST FORM <br /> F F g 2 5 2003 <br /> SAN COUNTY <br /> PUBLICO HEQALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br />