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SAN ,IOAQI 00UNTi- ENVIRONMENTAL HEALTAPARTM ENT <br />SERVICE REQt5EST <br />BCE #13418 <br />Type of Business or Property <br />FACILITY ID# <br />REQUEST # <br />ARCO Retail Gasoline Facility <br />7 <br />j J2- / <br />( <br />ACCEPTED BY: C, t_ l `i <br />�SERVICE <br />OWNER / OPERATOR <br />DATE 5 <br />BP West Coast Products LLC <br />CHECK if BILLINGADDRESSE] <br />FACILITY NAME <br />FAX # <br />ARCO Facility No. 2093 <br />SITE ADDRESS 3425 <br />CITY <br />Tracy Boulevard <br />Buena Park <br />Tracy <br />95376 <br />Street Number <br />Direction <br />Street Name <br />Invoice # <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P. 0. Box 5 015 Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Buena Park <br />CA 90622 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 510) 432-8397 <br />214-180-20 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />_ <br />J <br />7 <br />CONTRACTOR:ZSERVICE REQUESTORD <br />REQUESTOR <br />BP West Coast Products LLC <br />CHECK if BILLINGADDRESSm <br />BUSINESS NAME <br />ACCEPTED BY: C, t_ l `i <br />PHONE # EXT. <br />ARCO <br />DATE 5 <br />510 432-8397 <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: s'Cn c f <br />FAX # <br />P.O. Box 5015 <br />( ) <br />CITY <br />STATE ZIP <br />Buena Park <br />CA 90622 <br />BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business owner, operator or authorized agent of same. <br />acknowledge that all site andor 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 />1 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 Code.r..S7andards. STAII. and FEDERAL laws. � ay//4 <br />SIGNATURE: .:-'::jrDATE: <br />exia nigues ro�ec anner or <br />PROPERTI/BtslNESsOMNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT®Barghausen Consulting Engineers, Inc. <br />/l.IPPLI .-I S7 is nol the BILL[N6 P.41?7'). 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 COI INEY 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 />�Ec <br />MAY 13 Zoo$ <br />SAN JOAOUIN COUNTY <br />ENAROEp T ENT <br />ACCEPTED BY: C, t_ l `i <br />EMPLOYEE #: C) 5 Zf <br />DATE 5 <br />ASSIGNED TO:� <br />EMPLOYEE #: s'Cn c f <br />DATE: <br />5 s/0 <br />Date Service Completed (if already completed): <br />SERVICE CODE: / <br />Pi E:Z_-�tk� <br />Fee Amount: - �� 07 <br />Amount Paid <br />Payment Date <br />Payment Type ✓ <br />Invoice # <br />Check # b ll k'-1 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />