Laserfiche WebLink
SAN JOACI COUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas Station )0 �?(b o ri S P001(P c'lei{ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Tesoro Refining&Marketing Co. LLC <br /> FACILITY NAME <br /> Tesoro#68154 <br /> SITE ADDRESS 2500 W Lodi Avenue Lodi 95242 <br /> Street Number I Direction §triiet Name City Zia Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1910() Ridgewood Parkway <br /> Street Number Street Name <br /> CITY San Antonio STATE CA ZIP 78259 <br /> PHONE#1 Eu. APN# LAND USE APPLICATION# <br /> PHONE#2 Em BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Walton CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex'' <br /> Walton Engineering,Inc. (916)373-1152 <br /> HOME or MAILING ADDRESS FAx# <br /> P.O. Box 1025 ( )916 373-1172 <br /> CITY West Sacramento STATE CA ZIP 95620 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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, STATE an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �' �" f <br /> PROPERTY/BUSINESS OWNER❑ (OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT M Contractor <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It IS available and at the same time It IS provided t0 me Or <br /> my representative. pQ <br /> TYPE OF SERVICE REQUESTED: USIr 7 I / CFry <br /> COMMENTS: <br /> �q�7�AQUry I � <br /> `lh'p AN��U <br /> ACCEPTED BY: Ori Gl EMPLOYEE#: DATE: S '� <br /> ASSIGNED TO: 'l EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: lqo P/E: 2308 <br /> Fee Amount: L+ Amount Paid /'7 QD Payment DateY511 7 <br /> Payment Type Invoice# Check# S1 8 Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />