Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fuel Dispensing Facility �� �� � �M?, 00-7 W !�A <br /> OWNER/OPERATOR <br /> Tesoro Refining &Marketing Company LLC CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Tesoro site#68154 <br /> SITE ADDRESS 2500 West Lodi Lodi 95242 <br /> Street Number Direction St,.et Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 19100 Ridgewood Parkway <br /> Street Number Street Name <br /> CITY San Antonio STATE TX ZIP 78259 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 210 ) 626-6224 D <br /> PHONE#2 EAT. BOS DISTRICT11 LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> A&S Engineering/Ahmad Ghaderi CHECK If BILLING ADDRESS <br /> BUSINESS NAME A&S Engineering PHONE# ExT. <br /> 661 1 250-9300 <br /> HOME or MAILING ADDRESS FAx# <br /> 28405 Sand Canyon Road Suite B 1 661 )250-9333 <br /> CITY Canyon Country STATE CA ZIP 91387 <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 ENVIRONMENT HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed tome or my business as identified on is form. <br /> I also certify that I have prepared this application and that work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standcu ds,STATE and FEDE laws. <br /> APPLICANT'S SIGNATURE: DATE: 1c>/1 '3/`P1 p6. <br /> PROPERTV/BUSINESS OWNER❑ OPERATOR/ AGER ❑ OTHER AUTHORIZED AGENT IaAgentfor Tesoro <br /> If APPLICANT is not the B/LL/NG PA Tr 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: Plan Review for Turbine replacement. Replace existing MLLD's with ne ff UST's. <br /> COMMENTS: vt✓t f'c� ��� _ ^,,,.��46RECEIVED <br /> } OCT 18 2016 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> FALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 10- 7� <br /> ASSIGNED TO: ✓/..( EMPLOYEE#: DATE: ©_ <br /> Date Service Completed (If already completed): SERVICE CODE: P PIE: <br /> f C6 �oO W <br /> Fee Amount: 5c Amount Paid (p 2S. - Payment Date 10 1$) / <br /> Payment Type Invoice# Check# A4 9 a-- Received By: <br /> EHD 48-02-025JY ld SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />