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SAN JOAQU&OUNTY ENVIRONMENTAL HEALTAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Gas Dispensing Facility LfA S�-W-�F&Co Z <br /> OWNER/OPERATOR <br /> Tesoro Shell #68151 CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Tesoro Shell #68151 <br /> SITE ADDRESS 35 N. CHEROKEE LN. LODI 95240 <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 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT �( LOCATION CODE <br /> ( ) a 2. <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Angel Rodriguez CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT• <br /> Walton Engineering, Inc. 916 373-1165 <br /> HOME Or MAILING ADDRESS P.O. Box 1025 FAx <br /> 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 14EALTH 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 and that the work o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE d FEDERAL laws. �r <br /> APPLICANT'S SIGNATURE: DATE: I Z S IO <br /> PROPERTY/BUSINESS OWNER❑ /OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® e�'.� d11 u J- <br /> If APPLICANT 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 assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sar17g it is <br /> provided to me or my representative. AM.. <br /> TYPE OF SERVICE REQUESTED: 2-,3(-D? ' UST <br /> COMMENTS: 1 <br /> SCP 71Y MFbDu� <br /> '9RT��NT <br /> ACCEPTED BY: rnE(IJ E-:Z-- EMPLOYEE#: DATE: 2 <br /> ASSIGNED TO: Clj ccck- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: q� PIE: 2 3a,y <br /> Fee Amount: $ &34/.aD Amount Paid "O ,OD Payment Date W/Y- <br /> Payment Type 2-04--- Invoice# Check# S-3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />