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SAN JOAQUPOUNTY ENVIRONMENTAL HEALTH D&RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station AbuiS)C0-& 43-,,2-3 <br /> OWNER i OPERATOR <br /> BP West Coast Products LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME Arco 6347 <br /> SITE ADDRESS 2430J0e Pombo Parkway Tracy 95376 <br /> treet Number iretion Stmet Nome city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 6038 Street Number Street Name <br /> CITY <br /> Artesia STATE Ca. ziP 90702-6233 <br /> PHONE#') ExT• APN# LAND USE APPLICATION# <br /> (209) 466-6633 <br /> ff <br /> HONEK ExT• BOS DISTRICT 800 ) 525-5857 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Jim Cortez CHECK If BILLING ADDRESS 21 <br /> BUSINESS NAME PHONE# ExT. <br /> Charles E. Thomas Co. 310 323 - 6 730 259 <br /> HOME or MAILING ADDRESS FAX# <br /> 13701 S. Alma Avenue (310) 715 - 8626 <br /> CITY Gardena STATE Ca. 71P 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 1 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 an/d,�FEDWL L laws. <br /> APPLICANT'S SIGNATURE: Cil/ DATE: <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/ AGER ❑ OTHER AUTHORIZEDAGENTQ Permit Technician <br /> If APPLICANT is not the BILLING 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. <br /> TYPE OF SERVICE REQUESTED: l\/ED <br /> COMMENTS: <br /> DEC 19 2005 <br /> SAN JOAOVIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: / <br /> ASSIGNED TO: EMPLOYEE#: O 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: b <br /> Fee Amount: `r Amount Paid -717_C)-D Payment Date <br /> Payment Type Invoice# Check# ` b t{ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />