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SAN JOAQu1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # gas station 0 2 Sic ou & F'/�/U OWNER / OPERATOR ASSIGNED TO: ` - CHECK R Tesoro Corporation Date Service Completed (if already completed): t31LUNG ADD .gesso FACILITY NAME Shell (Tesoro) 213-6038 HOME or MAILING ADDRESS 680 SITE ADDRESS 3!N Cherokeeane, Lodi I CA 95240 Quinn Ave Invoice # (408 ) 213-6026 Street Number 01rutona ZIP 95112 city HOME or MAILING ADDRESS (if Different from Site Address) Street Number StmLNamy CITY STATE ZIP PHONE #1 Exr. APN E LAND USE APPUCA71ON iK ( 1 0(j-3- ( -0 3 PHONE 82 EXT. ( 1cc BOS DISTRICT LOcAT1ON CODE T tlupl I CONTRACTOR / SERVICE REQUESTOR REQUESTOR i COMMENTS: Marty Weithman ACCEPTED BY: CHECK If BILLING ADDRESS BUSINESS NAME Service Station Systems, Inc. ASSIGNED TO: ` - PHONE# EXT. Date Service Completed (if already completed): 408 213-6038 HOME or MAILING ADDRESS 680 Amount Paid 13 FAX# Payment Date a g l Quinn Ave Invoice # (408 ) 213-6026 CITY San Jose STATE CA ZIP 95112 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, 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 I 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:.( f -� -'JL . DATE: 1/27/2014 PROPERTY/ BUSINESS OwNERQ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ✓❑ Compliance Officer IfAPPLICANT is not the Biam 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 in&peC 7V- ( i COMMENTS: W2014 ACCEPTED BY: EMPLOYEE #: 16, 7 U DATE, ASSIGNED TO: ` - EMPLOYEE #: / Lf -2,Z DATE: Date Service Completed (if already completed): SERVICE CODE: (C?'� P / E: '230 Fee Amount: 7� S Amount Paid 13 e— Payment Date a g l Payment Type t/ Invoice # Check #- %� ecelve By EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2D03