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AECEIVEDSAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT SERVICE REQUEST �a� �`' `� t 2017 Type of Business or Property FACILITY ID !F SERVICE REQUEST Fuel Dispensing Facility EN IRONMENTAL HEALTH OWNER / OPERATOR MR , ipsl rz Tesoro Refining & Marketing Company LLC CHECK If BILLING ADDRESS❑ FACILITY NAME Ext. Tesoro Site # 68152 Fee Amount: SITE ADDRESS 401 West Kettleman Lodi 95240 Street Number Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 19100Ridgewood Parkway 28405 Sand Canyon Road, Suite "B" tr um erStreet Name CITY San Antonio STATE TX ZIP 78259 x* PHONE #f EXT, APN # LAND USE APPLICATION # ( 210 ) 626-6224 PHONE #2 Ext. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR COMMENTS: #443168901 STP -MLD Mechanical Leak Detectors for existing UST's. Install Bravo RC -Series Snap -Lock Sump Lid on the 87 STP Sump. ACCEPTED BY: A & S Engineering/ Ahmad Ghaded DATE: CHECK if BILLING ADDRESS BUSINESS NAME A & S Engineering DATE: PHONE Ext. P / E: Fee Amount: 661 250-9300 HOME or MAILING ADDRESS Invoice # FAX # Received By: 28405 Sand Canyon Road, Suite "B" ( 661 )250-9333 CITY Canyon Country STATE CA ZIP 91387 BILLING ACKNOWLEDGEMENT: I, the undersigned propepty or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENvutoNmr•.N•r IEALTH DrPARTMENr hourly charges associated with this project or activity will be billed to me or my business as identified on t s form. I also certify that I have prepared this application and that t work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDI; , laws. ) APPLICANT'S SIGNATURE:DAT-11.7t/�� 7 E• PROPERTY/BusLNEss OWNER❑ OPERATOR/ AGER ❑ O7ritERAUTHORizEDAGENT fif AgentforTesoro IfAPPL/cfbvT is no11/re BiLLnG MT}proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN CoumrY ENviRoNNtLN*rAL HEALTI I DEPARTNIE'NT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Plan Review for Turbine Replacement. Replace existing MLD's with new FE Petro, Model COMMENTS: #443168901 STP -MLD Mechanical Leak Detectors for existing UST's. Install Bravo RC -Series Snap -Lock Sump Lid on the 87 STP Sump. ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: P / E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003