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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 TA0000 t3g UTY790 <br /> OWNER / OPERATOR <br /> Tesoro #68153 CHECK If BILLING ADDRESS ® <br /> FACILITY NAME <br /> Tesoro #68153 <br /> SITE ADDRESS 2448 W . Kettleman LODI 95242 <br /> Street Number Direction Street Name Ci 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 /> ( 1 1 <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 EDEERRAL laws . <br /> APPLICANT'S SIGNATURE : ��— DATE : ( % ( 1 �ljr <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PART1% 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 environmentaUsi assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED : i <br /> COMMENTS: S. <br /> y4JN�Ro U/� c <br /> ry°Fp RT��y� <br /> ACCEPTED BY: /^n ` �I. /� N/ ^ EMPLOYEE #: DATE : f O 1 J <br /> ASSIGNED TO : 5 ` L / l t{lJ0 �V EMPLOYEE #: ` ( � -( DATE: !/ r <br /> Date Service Completed (if alikady completed) : SERVICE CODE: n PIE: j <br /> Fee Amount: S --- -- Amount Pai Payment Date f Q <br /> Payment Type ��� Invoice # Check # <714 � � Received By : <br /> EHD 4&02-025 <br /> m it SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 L ! V <br />