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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID # SERVICE REQUEST # <br /> Type of Business or Property MCC'IIIi oo 90� <br /> Retail Gas Dispensing Facility C�l`1i C <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS ❑ <br /> Tesoro #68150 <br /> FACILITY NAME Tesoro #68150 <br /> SITE ADDRESS E . Hwy 88 Lockeford 95237 <br /> 13975 zip <br /> Code <br /> Street Number Direction <br /> Street Name NINE <br /> HOME or MAILING ADDRESS (if Different from Site Address) Street Name <br /> Street Number <br /> STATE ZIP <br /> CITY <br /> I NINE <br /> OEM NINE ME:XT. APIN. <br /> # LAND USE APPLICATION # <br /> PHONE #1 <br /> ( ) BOS DISTRICT LOCATION CODE <br /> PHONE #2 ExT. <br /> CONTRACTOR / SERVICE REQUESTOR <br /> CHECK if BILLING ADDRESS ® <br /> REQUESTOR Michael Walton <br /> PHONE # Exr . <br /> BUSINESS NAME 916 373- 1165 <br /> Walton Engineering , Inc . <br /> HOME or MAILING ADDRESS P . O . Box 1025 916 ) 373- 1172 <br /> STATE CA ZIP 95691 <br /> CITY West Sacramento <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 FEDERAL laws . / O� / <br /> (//!/r DATE : S <br /> APPLICANT' S SIGNATURE : AL1 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® r Title If APPLICANT is not the BILGING PARTY, proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, I , the owner or operator of the propert located at the <br /> Merit <br /> above site address , hereby authorize the release of any and all results , geotechnical dataand/or <br /> isavailableand attal �x <br /> ab � � V <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as <br /> provided to me or my representative . <br /> Y 2 <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> H CNVOIRONMIIE CC <br /> OUN7Y <br /> N,'1 AY 2 4 0 OEPARTMEN i <br /> ENVIRONMENTAL IJEAL:Vi <br /> EMPLOYEE # : J(� r} { CEP SAT v1E. NT 9 - g l �Cj <br /> ACCEPTED BY : `Ci J , L� V 1 <br /> EMPLOYEE #: DATE : � 'r 9 <br /> ASSIGNED TO : <br /> eady completed) : <br /> SERVICE CODE : 1 PIE : <br /> Date Service Completed ( if air <br /> ,� <br /> Amount Paid L� � — Payment Date J� 2 C/ <br /> Fee Amount: y <br /> Received By : <br /> Payment Type ✓ Invoice # <br /> Check # <br /> SR FORM (Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11 /17/2003 <br />