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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Existing to remain retail fuel dispensing facility R <br /> OWNER/OPERATOR <br /> Tesoro Sierra Properties LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Store#6187 <br /> SITE ADDRESS 2705 Country Club Blvd Stockton 95204 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 19100 Ridgewood Parkway <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> San Antonio TX 78259 <br /> PHONE#1 For this project Exr. APN# LAND USE APPLICATION# <br /> (661 ) 250-9333 121-210-08 <br /> PHONE#2 Esr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A&S Engineering <br /> CHECK If BILLING ADDRESSED <br /> BUSINESS NAME A&S Engineering PHONE# EZT' <br /> 661 250-9333 <br /> HOME or MAILING ADDRESS FAx# <br /> 28405 Sand Canyon Rd Suite B I ( ) <br /> CITY Canyon Country <br /> STATE CA ZIP 91387 <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 FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE:r 7/30/2019 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZEDAG"-r Authorized Agent <br /> /fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 ENVIRDNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: 41Z4 AL1� 4 III <br /> �C hj <br /> COMMENTS: qV�'/I O <br /> j '9B <br /> %''OqQ ?419 <br /> M ,O� � 7), <br /> ACCEPTED BY: EMPLOYEE M r„Z,1'7 DATE: /' <br /> ASSIGNED TO: r Z EMPLOYEE#: 3J J DATE: t <br /> Date Service Completed (if already completed): SERVICE CODE: 23 P I . O <br /> Fee Amount: Amount Pai ,OD Payment Date $� <br /> Payment Type (. Invoice# Check# �D�fGJ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />