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SAN JOARIN COUNTY ENVIRONMENTAL HEALTD EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station(; , t'j �� OWNER 1 OPERATOR CHECKIf BILLINGADDRESSM Tesoro Refining and Marketing Copany CHECK If SiLUNG ADDRESS❑ FACILITY NAME Shell (Tesoro) EXT' SITE ADDRESS 35 N Cherokeeane, Lodi CA 95240 213-6038 HOME or MAILING ADDRESS SERVICE CODE: Stroot Numbercity Fee Amount: % ` S 680 Quinn Ave - fl4-�' (408 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 3450 STATE CA South 344th Way Street Number Strool a CITY Auburn STATE WA ZIP 98001 PHONE #i ExT• APN71,, LAND USE APPLICATION ( 253M68700 (( 6 `t I , o /J PHONE#2 EXT. ( ) BOSDISTMCT LoCAnoNCODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR PAYME COMMENTS: Marty Weithman ACCEPTED BY: f\4 . q --p I CHECKIf BILLINGADDRESSM BUSINESS NAME Service Station Systems, Inc. PHONE# EXT' EMPLOYEE #: DATE: Z 408 213-6038 HOME or MAILING ADDRESS SERVICE CODE: FAx# Fee Amount: % ` S 680 Quinn Ave - fl4-�' (408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:I L, L" Et,t1 �,t-y DATE: 2/15/2013 PROPERTY/BUsINESBOWNER❑ OPERATOR/ MANAGER ED OTHER AUTHORIZED AGENT E) Compliance Officer 1fAPPLICANT is not the BILLING PARTY, 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: UST inspection PAYME COMMENTS: RrrG' FEB 19 2013 SA j0A111MENTAL N LTH DEPARTMENT ACCEPTED BY: f\4 . q --p I EMPLOYEE #: DATE: ASSIGNED TO: C r, EMPLOYEE #: DATE: Z I Date Service Completed (H already completed): SERVICE CODE: PIE: C� Fee Amount: % ` S Amount Paid - fl4-�' Payment Date Payment Type y� Invoice # Check III D Received By: EHD 46-02-025 SR FORM (Golden Rod) REVISED 11/17/2D03