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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property AMPM Convienece Store FACILITY ID # <br />z."7-3 1 0 <br />SERVICE REQUEST # <br />SIZO08-3-q( G. <br />OWNER / OPERATOR <br />BP Products North America, Inc. CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ampm 7092 <br />SITE ADDRESS <br />2 510 <br />Street Number <br />WEST <br />Direction SouthareeeMit29 West Frontage Rd <br />STocKToN <br />City <br />95215 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 9600 <br />Street Number <br />JAMES THORNTON WAY <br />Street Name <br />CITY LOUISVILLE STATE ZIP <br />KY 40245 <br />PHONE #1 EXT. <br />( 714 ) 865-2610 <br />APN # I LAND USE APPLICATION # <br />171-300-240-000 <br />PHONE #2 Err. <br />( ) II <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Julie Bernardi for AMPM CHECK if BILLING ADDRESS El <br />BUSINESS NAME AMPM 7092 PHONE # <br />( 209-48-2438 <br />EXT. <br />HOME or MAILING ADDRESS Same as above <br />FAX # <br />( / <br />CITY STATE ZIP <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 TAT and FEDERAL laws,. <br />wtaiLdee,' A PFETCA ITT'S ETGITATTJPE: <br />A/ilusiNEss OWNER CI OPERATOR / MANAGER 1:1 OTHER AUTHORIZED AGENT KLicensing & Regustration Mgr P-uediM <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: Change of Ownership / remove former operator Strauch Management Co. effective 4/29/24 - no other site changes <br />. Ai ripli <br />COMMENTS: Bp will own and operate the site <br /> <br />4PR 0 n <br />1._, •Aii )-,',4Qu a , <br />"E:4 L 7-Z5'0/wig' v, Co L <br />" D PAici-Alr'l . TA46 <br />ACCEPTED BY: 0 e4. r-fri.t.es-Scifi' EMPLOYEE #: DATE: <br />ASSIGNED TO: 11 c-i- r-C7 EMPLOYEE #: DATE: 4 ..... s - 2.4 <br />Date Service Completed (if already completed): SERVICE CODE: Crz, i P / E: <br />Fee Amount: ,.$/, 2 . 00 Amount Pai0 --) ..,<. OD Payment Date LihAtit <br />Payment Type 62...41k+ Invoice # Check # ) 7(.1.1,..5-, fis,7::- Received By:afly <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />DATE:04/08/2024 <br />PRDSLIq1ot4