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0 if R E Gir E I iEH D <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ?,3. <br />SERVICE REQUEST <br />2017 <br />Type of Business or Property <br />FACILITY ID If SERVICE REQUEST # <br />Fuel Dispensing Facility <br />7'1 <br />OWNER / OPERATOR <br />a n ,7777711, <br />Tesoro Refining & Marketing Company LLC <br />CHECK If BILLING ADDRESa❑ <br />FACILITY NAME <br />661 250-9300 <br />Tesoro site # 68152 <br />DATE: <br />SITE ADDRESS <br />401 <br />West <br />Kettleman <br />( 661 )250-9333 <br />- <br />Lodi <br />95240 <br />Street Number <br />Payment Type <br />Invoice # <br />city <br />z10 Cod* <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />19100 <br />TRidgewood Parkway <br />Street Nub.rStreet <br />Name <br />CITY <br />San Antonio <br />STATE TX ZIP 78259 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 210 ) 626-6224 <br />PHONE #2 Ext. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />Plan Review for Turbine Replacement. Replace existing MLD's with new FE Petro MLD's for <br />A & S Engineering/ Ahmad Ghaderi <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />A & S Engineering <br />PHONE# ExT. <br />DATE: <br />ASSIGNED TO: <br />661 250-9300 <br />HOME or MAILING ADDRESS <br />DATE: <br />FAX # <br />28405 Sand Canyon Road Suite B <br />P I E: <br />( 661 )250-9333 <br />CIN Canyon Country <br />STATE CA ZIP 91387 <br />TH <br />BILLING ACKNOWLEDGEMENT: I, the undersigned pro My or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENvMoNMI:N HEAI.'rII litiPARThftsNl' hourly charges associated with this project <br />or activity will be billed to me or my business as identified o his form. <br />I also certify that I have prepared this application and that a work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FED AL laws. <br />APPLICANT'S SIGNATURE: DA'rE : Lif I'S b2 o n <br />PROPERTY/ BUSINESS OWNER OPFRATO >VLILNAGER O OTHER Aurnoluzw AGENTS( Agent for Tesoro <br />IfAPPLICIANT is not the BILLI m PARTY, proof of authorization to sign is required Titre <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 ENViRoNvtENTAL HEALTH DEPAR'ImENT 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: <br />Plan Review for Turbine Replacement. Replace existing MLD's with new FE Petro MLD's for <br />COMMENTS: <br />existing UST's. Install Bravo Sump Lid on the 87 STP Sump. <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />