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�i <br /> All <br /> 0�lnN� <br /> } <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP A� fk VMENT nd <br /> SERVICE REQUEST <br /> Type of �ejjpo br Iroperty FACILITY ID # E ;; U ST # <br /> C) <br /> � \ �M Q � T� IJ <br /> O NER / OPERATOR <br /> Tesoro CHECK If BILLING ADDRESSL] <br /> FACILITY NAME <br /> Tesoro # 68221 <br /> SITE ADDRESS 2705 Country Club Blvd, <br /> Stockton CA <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 /> ( ) <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Walton Engineering, Inc CHECK if BI IN ADDRM ® <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 - 1173 <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 DEPARTtiIENT 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 applic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Orrdinance Codes, Standards, T E and FEDE L laws . <br /> APPLICANT' S SIGNATURE : DATEID <br /> : <br /> PROPERTY / BUSINESS OwNER ❑ OPERATOR / Mi AGER ❑ OTHER AUTHORIZED AGENT Contractor I <br /> If APPLICANT is not the BI1LING 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 same time it is <br /> provided to me or my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> ACCEPTED BY: EMPLOYEE #: DTE : <br /> ASSIGNED TO : P O\ E #: <br /> Date Service Completed (if alreadycompleted) : a G SERVICE CODE : PIE <br /> Fee Amount: Amount Paid J Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 <br /> REVISED 11 /17/2003 SR FORM (Golden Rod) <br />