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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gas Dispensing Facility VA 0Op,� 4 � �P,, 00 D2 <br /> OWNER / OPERATOR <br /> Tesoro #68221 CHECK if BILLING ADDRESS D <br /> FACILITY NAME <br /> Tesoro #68221 <br /> SITE ADDRESS 2705 Country Club Stockton 95204 <br /> Street Number Direction Street Name Cit Zi 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 /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and F D RAL laws . a q <br /> APPLICANT' S SIGNATURE : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® V/ <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 l'I�eeyysame time it is <br /> provided to me or my representative . ^1 <br /> TYPE OF SERVICE REQUESTED : 71 a 1i 1Vr <br /> SA kC4 <br /> COMMENTS : 4Y 0 <br /> H ESdoR QtIV <br /> Ty 0&MJ�7y <br /> T <br /> ACCEPTED BY : , ;1 f1 EMPLOYEE # : Ci j ) (Q .)- DATE : �t(2 <br /> ASSIGNED TO : tit vv EMPLOYEE # : l l�iv DATE : <br /> Date Service Completed ( if already Completed ) : SERVICE CODE : Q PIE : <br /> Fee Amount: t7 - Amount Pad LLI�l � Payment Date <br /> I� ' / <br /> Payment Type Invoice # Check # S� �l �l Rece ved By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />