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SAN JOAQUICOUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ID # Barghausen Consulting Engineers, Inc. SERVICE REQUES # BUSINESS NAME 2FACILITY IL�11i�^�� -'rV'��+'�� ARCO Retail Gasoline Facility 425 251-6222 HOME or MAILING ADDRESS ASSIGNED TO: OWNER/ OPERATOR 18215 - 72nd Avenue South EMPLOYEE #: 6 ( ) CITY CHECK If BILLING ADDRESS BP West Coast Products. LLC P I E: FACILITY NAME - '7 S"' cn. Amount Paid ARCO (Loc. No. 2133) Payment Date B o7 SITE ADDRESS 2908 Benjamin Holt Drive Stockton 95207 Street Number Direction Street Name Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) BP West Coast Products, LLC Street Number P - O. Box 5077 Street Name CITY STATE ZIP Buena Park CA 90622 PHONE #1 EXT- APN # LAND USE APPLICATION # ( 714) 670-5152 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS Barghausen Consulting Engineers, Inc. COMMENTS: BUSINESS NAME RECE IVEU OCT 21 2011 1 SAN JOAQUIN COUNTY EWRONMEHTAL HEALTH DEPARTMENT PHONE # EXT. ARCO (Loc No. 2133) 425 251-6222 HOME or MAILING ADDRESS ASSIGNED TO: FAX # 18215 - 72nd Avenue South EMPLOYEE #: 6 ( ) CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: —�-� Inigues DATE: October 20, 2011 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Project Planner If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Consultant A -K Scott Listar AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: PAYMENT COMMENTS: RECE IVEU OCT 21 2011 1 SAN JOAQUIN COUNTY EWRONMEHTAL HEALTH DEPARTMENT ACCEPTED BY: U �t t� EMPLOYEE #: DATE: ' 1.2- ( f' ASSIGNED TO: Q A t.• .. n EMPLOYEE #: 6 DATE: (O L2-( f� Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: - '7 S"' cn. Amount Paid -� d20 Payment Date B o7 Payment Type Invoice # Check #1 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003