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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 <br /> OWNER / OPERATOR <br /> Tesoro #68153 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Tesoro #68153 <br /> SITEADDRESS 2448 W . Kettleman LODI 95242 <br /> Street Number Direction I Street Name Cit 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 /> ( ) I <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 EDERAL laws . <br /> APPLICANT'S SIGNATURE : DATE ; <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ BOTHER 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/sI assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th� e it is <br /> provided to me or my representative . J <br /> Zvi <br /> { �j <br /> TYPE OF SERVICE REQUESTED : t ,S ICJL% orp <br /> COMMENTS : Sq <br /> y�) <br /> JOA <br /> y�Fp l y X44�- <br /> T <br /> ACCEPTED BY: /.^ n �I /S�r ry/ ,, EMPLOYEE # : U DATE : <br /> ASSIGNED TO : P , C V �'h27 �V EMPLOYEE #: ` (� �. r DATE : <br /> Date Service Completed ( if alVeady completed) : SERVICE CODE : O P 1 E : '� 6 9 <br /> 1 <br /> Fee Amount: S� .� Amount Paid/If7D� D� Payment Date <br /> Payment Type SIL Invoice # Check # Sy � � G Received By : <br /> EHD 48-02-025 D , / rn P D� SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 /y O <br />