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SAN JOAQUIPOUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> Retail Gas Dispensing Facility D <br /> OWNER/OPERATOR <br /> Tesoro#68221 CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Tesoro #68221 <br /> SITE ADDRESS 2705 Country Club Stockton 95204 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 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 a d that the work to be p rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S ATE and DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site ssessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the is <br /> provided to me or my represen i e. <br /> TYPE OF SERVICE REQUESTED: MAW <br /> COMMENTS: S <br /> ��0 201 <br /> � QU/N c 8 <br /> THCo pN MFH <br /> T <br /> ACCEPTED BY: W\` EMPLOYEE#: DATE: <br /> ASSIGNED TO: r� EMPLOYEE#: DATE: <br /> edy SERVICE CODE: 14 P 1 E:Date Service Completed (if alr (� <br /> Fee Amount: Amount Pai �Bc� Payment Date O D <br /> Payment Type Invoice# Check# 5�L242— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />