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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # � DQ SERVICE REQUEST # <br /> Retail Gas Dispensing Facility FAQ 0 O ✓ � 003 SI' t <br /> OWNER / OPERATOR <br /> Tesoro #68152 CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Tesoro #68152 <br /> SITE ADDRESS 401W . Kettleman LODI 95240 <br /> Street Number Direction Street Name city 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 /> ( ) 0 51301q <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 an FEDERAL laws . <br /> APPLICANT' S SIGNATURE : C <br /> � DATE : I 0 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® ) <br /> IfAPPLICANT 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 Sal time it is <br /> provided to me or my representative . <br /> TYPE OF SERVICE REQUESTED : 1 5T <br /> COMMENTS: T <br /> Silvio, <br /> 01 <br /> a <br /> ItFq /N <br /> yCo�OEpgR <br /> �Y <br /> ACCEPTED BY: A,� +/�j ^ EMPLOYEE #: �% "7 DATE : / 0 <br /> ASSIGNED TO : // v EMPLOYEE #: (7p l7 '1 DATE : t O 471 7 <br /> Date Service Completed ( if already completed) : SERVICE CODE : ' el PIE : <br /> Fee Amount: ,� Amount Pai � . D� Payment Date <br /> Payment Type C invoice # Check # j G S Rece ved By : <br /> EHD 48-02-025 , /�a� —G'_ 2z8• O SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 oyM �PJJJLII� <br />