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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ARCO retail gasoline facility <br /> OWNER/OPERATOR BP West Coast Products LLC <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO (Loc. No. 213 3) <br /> SITE ADDRESS 2908 Benjamin Holt Drive Stockton 95207 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY Buena Park STATE ZIP <br /> CA 90622 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 510 ) 432-8397 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR BP West Coast Products <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME ARCO (Loc. No. 2133 PHONE# ExT. <br /> 510 432-8397 <br /> HOME or MAILING ADDRESS P.O. Box 5015 FAX# <br /> CITY Buena Park STATE CA ZIP 90622 <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' <br /> t March 14, 2008 <br /> .� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Project Planner for Mark <br /> If APPL/CANT is not the BILGING PARTY,proof of authorization to sign is required Title Murgash <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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />