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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 />5 t i <br />SERVICE REQUEST # <br />svaea El ci k-i- <br />OWNER / OPERATOR <br />BP Products North America, Inc. CHECK if BILLING ADDRESS <br />FACILITY NAME ampm 7049 <br />SITE ADDRESS <br />800 <br />Street Number <br />EAST <br />Direction E Kettleman Ln. <br />LODI <br />City <br />95240 <br />Zio 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 # <br />06102001 <br />LAND USE APPLICATION # <br />PHONE #2 E. <br />( ) <br />BOS DISTRICT <br />II <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Julie Bernardi for AMPM CHECK if BILLING ADDRESS <br />BUSINESS NAME AMPM 7049 PHONE # Err. <br />( 209-334-3678 <br />HOME or MAILING ADDRESS Same as above <br />Fax # <br />( ) <br />Cry 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 Iowa, <br />ge12.4444.C4. <br />A PFLICA ITT'S STGLTATUFE: <br /> <br />DATE:04/08/2024 <br /> <br />PRO! BUSINESS OWNER CI 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 theisame 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 5/2/24- no other site changes rN't-Ce" 1CN <br />COMMENTS: BP will own and operate the site OR on <br />8,4N .Y 47n22 , <br />'c7 <br />6t4 iVrir/04/j/N CO <br />/.1 tZ7z1/1/417' °A/TY 44?7.4.14/. <br />4,ir <br />ACCEPTED BY: azera e4 a EMPLOYEE #: DATE: 4-_5.,244 <br />ASSIGN ED TO: Rt 1 a EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: / PI E: <br />Fee Amount: $102 .00 Amount Paid K}os, #-//.. -) 00 Payment Date <br />Payment Type Lt. Invoice # Check # 1 Lf6.4, )56, Received By: 57)--- <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />Op LP