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1 <br /> ' SAN JOAQUIN4 WCOUNTY ENVIRONMENTAL HEALT DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property\ FACILITY ID# Service Request# <br /> Gas Station �' DUG+ �?b 3 -�Sk 00 1 J�¢� <br /> Owner/Operator 1 X 1 <br /> BP West Coast Products, LLC Check if Billing Address <br /> Facility Name <br /> ARCO 2130 (N-84) <br /> Site Address 7906N EI Dorado Street Stockton 95210 <br /> Street Number Direction Street Name City Zip Code <br /> Home or Mailing Address(If Different from Site Address) 4 CenterPointe Dr <br /> Street Number Street Name <br /> City La Palma State CA Zip 90623 <br /> Phone#1 Ext. APN# Land Use Application# <br /> (209) 649-3335 <br /> Phone#2 Ext. BOS District Location Code <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Requestor Lori Freshour Check if BILLING ADDRESS [ ] <br /> E=N � <br /> Business Name Tait Environmental Systems RECEIVE " Phone# Ext. <br /> (916) 858-1090 <br /> Home or Mailing Address 3283 Luyung Dr I FAX# <br /> UIN COUNTY (916) 858-1011 <br /> City Rancho Cordova PUBLIC HEALT <br /> I:NVIR0M1ENTAI HEALTH DIVISIttate CA zip 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: //7!1ADate: <br /> PROPERTY OWNER/BUSINESS OWNER[ ] OPERATOR/MANAGER[ ] OTHER AUTHORIZED AGENT [X] Compliance Mgr <br /> If applicant is not the BILLING PAR TYproof 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 Rested: Repair a ro 1 <br /> Commentsr Replaced 4 Existing Drop Tubes (OPW 61 SO-410C-EVR) In all products with new OPW 61 SO-410C <br /> EVR Drop Tubes. _ <br /> Approved by: {�---- `—� Employee#: V,6 Date: l© 7 d <br /> Assigned to: Employee#: �''�'1� Date: 1O '7 D-3 <br /> Date Service Completed(If already completed) Service Code: PIE- -� 30 <br /> Fee Amount: — I Amount Paid / Payment Date: I 3 <br /> Payment Type Invoice# Check# t? � Received by: V 0 <br /> EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FORM <br />