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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> �T RA WO I <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gas Dispensing Facility <br /> OWNER / OPERATOR <br /> Tesoro #68222 CHECK if BILLINGADDRESSE] <br /> FACILITY NAME <br /> Tesoro #68222 <br /> SITE ADDRESS 2132 E . Mariposa Road Stockton 95205 <br /> Street Number Direction I Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Michael Walton CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT. <br /> Walton Engineering , Inc . 916 373- 1165 <br /> HOME or MAILING ADDRESS FAX # <br /> P . O . Box 1025 ( 916 ) 373- 1172 <br /> CITY West Sacramento STATE CA ZIP 95691 <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, STATE d FEDERAL laws . <br /> APPLICANT' S SIGNATURE : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1, 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 : S �• T <br /> COMMENTS : <br /> SDEC 10 <br /> 1018 <br /> RpINENVICoulo <br /> yyEALTy pEAERM <br /> ACCEPTED BY : EMPLOYEE #: qA0Ail/ DATE : ( <br /> ASSIGNED TO : lM� EMPLOYEE # : DATE : _ 10 , � L <br /> Date Service Completed ( if already completed) : SERVICE CODE : I C( <br /> PIE : D1 <br /> Fee Amount: u Amount Paid q - D p Payment Date � a-I 1 D / I <br /> Payment Type V/ Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />