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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 SO 2-1 <br />SERVICE REQUEST # <br />sizcom8 4 9/ 5 <br />OWNER / OPERATOR <br />BP Products North America, Inc. CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ampm 7147 <br />SITE ADDRESS <br />1206 <br />Street Number <br />EAST <br />Direction E MARCH :LANE <br />SToCKTON <br />City <br />95210 <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 />Cm( LOUISVILLE STATE ZIP <br />KY 40245 <br />PHONE #1 ExT. <br />( 714 ) 865-2610 <br />APN # <br />10416004 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Julie Bernardi for AMPM CHECK if BILLING ADDRESS <br />BUSINESS NAME AMPM 7147 <br />PHONE # EXT. <br />( 209-956-2032 <br />HOME or MAILING ADDRESS Same as above <br />Fax # <br />( ) <br />Crrv 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 and FEDERAL laws, <br />ge.Adts44.4 . <br />APPjCAITTS 1311CrI 1 ATUFE: <br />P-ROPWHBUSINEss OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT KLicensing & Regustration Mgr <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 4/30/24 - no other site changes REC. giCA <br />COMMENTS: Bp will own and operate the site <br />'C) 0 <br />APR 09 <br />2024 s a N J o A <br />,EALTH -NmEtv°1-IN <br />AR <br />evviii'„QuiN c <br />DEPAR TA L Tmeh <br />ACCEPTED BY: 6....e,t,c,(1,4 eS C-4 EMPLOYEE #: DATE: 1,12, 2_1_ <br />ASSIGN ED TO: . eselw 0 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 67e.0( PIE: f- cee L CI i <br />Fee Amount: $ k 2 .00 o Amount Paid Payment Date 4/4 <br />Payment Type 6eeXt Invoice # Check # I 7.1 4--.(e ,7 ,3D Received By: dTh <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />"Ka vocli 5 <br />DATE:04/08/2024