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SAN JOQ A UIN40OUNTY ENVIRONMENTAL HEALTOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property\ <br />FACILITY ID# <br />Service Request # <br />Gas Station <br />3, C? <br />Home or Mailing Address 3283 Luyung Dr <br />Owner / Operator 1 X I <br />BP West Coast Products, LLC Check if Billing Address <br />Facility Name <br />ARCO 5450 <br />Site Address 1617 <br />W <br />Fremont <br />Stockton <br />95203 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />Home or Mailing Address (If Different from Site Address) 4 <br />CenterPointe Dr <br />Street Number <br />Street Name <br />City La Palma State CA zip 90623 <br />Phone #1 Ext. <br />APN # <br />Land Use Application # <br />( 209 ) 649-3335 <br />Phone #2 Ext. <br />BO S District <br />Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor Lori Freshour <br />Check if BILLING ADDRESS [ ] <br />Business Name Tait Environmental Systems <br />Phone # Ext. <br />( 916 ) 858-1090 <br />Home or Mailing Address 3283 Luyung Dr <br />Comments: <br />FAX # <br />( 916) 858-1011 <br />city Rancho Cordova <br />State 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,lST�AATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Date:_ <br />D <br />PROPERTY OWNER / BUSINESS OWNER [ ] OPERATOR / MANAGER [ ] OTHER AUTHORIZED AGENT <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 prope <br />Above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sit�' <br />Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and RM <br />same tunejis <br />provided to me or my representative. ot,I <br />Type of Service Requested: <br />Repair / Retrofit <br />�OAO�iN StRON <br />V CESsI <br />SAN NEAISN jFa p1V1 <br />Comments: <br />I�E <br />LNVIRONKI <br />Replaced Existi g Drop Tu <br />e (0 PW 61 SO-41OC- EVR) I n 87 Master with new 0 P 61 S0 -410C EVR Dr p Tu e <br />Approved by: f <br />Employee #: <br />Date: 4 z <br />Assigned to: <br />Employee #: <br />�� Date: <br />Date Service Completed (If already completed) Service Code: <br />P/E: <br />Fee Amount: <br />Amount Paid �.a(� i — <br />Payment Date: a yQ3 <br />Payment Type ✓ <br />Invoice# Check # a <br />Received By: <br />EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FORM <br />