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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH•PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station 15P-Vz -- 2 r <br /> OWNER/OPERATOR <br /> BP West Coast Products LLC CHECKlfBILLING ADDRESSO <br /> FACILITY NAME Arco 5450 <br /> SITE ADDRESS 1617W Fremont Stockton 95203 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 6038 Street Number Street Name <br /> CITY Artesia STATE Ca. 'P 90702-6233 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 466-6633 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( $oo ) 525-5857 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jim Cortez CHECK if BILLING ADDRESS 21 <br /> BUSINESS NAMECharles E. Thomas Co. PHONEEXT <br /> # <br /> 310 323 - 6730 259 <br /> HOME or MAILING ADDRESS FAX# <br /> 13701 S. Alma Avenue ( 310) 715 - 8626 <br /> CITY Gardena STATE Ca. 7J 90249 <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,ST and F E L laws. <br /> APPLICANT'S SIGNATURE: 12-111r DATE:71 <br /> S <br /> PROPERTY/BUSINESS OWNER OPERATOR/M6Z.R ❑ OTHER AUTHORIZED AGENT Pe rm It Technician <br /> If APPLicANT is not the BILL/NG 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. ENT <br /> tu <br /> TYPE OF SERVICE REQUESTED: RECEIV <br /> COMMENTS: 2005 <br /> DEC 1 <br /> SAN 30AQUIN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ? DATE:/ <br /> ASSIGNED TO: EMPLOYEE#: JO DATE:t <br /> Date Service Completed (if already completed): SERVICE CODE: 15 g P I E: <br /> Fee Amount: J 17tJ" I Amount Paid Z 7 Payment Date ` ( �(C) S <br /> Payment Type Invoice# Check# �,(E Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />