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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 Gas Station X6021 y S 'P*� a 4 l(3 0 a 3 (9 <br /> OWNER / OPERATOR <br /> Western Refining Retail LLC CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Tesoro ( Speedway) #68221 <br /> SITE ADDRESS 2705 County Club Blvd Stockton 95204 <br /> Street Number Direction Street Name City Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P . O Box 711 Attn : Gasoline Compliance , LOC 148 Street Number Street Name PAY <br /> cNT <br /> CITY Dallas , TX 75221 STATE ZIP ` D <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # 1 U Z124 <br /> ( 661 ) 250-9300 SAN JOAQU <br /> PHONE #2 EXT. q BOSDISTRICT 1 /A>LI EN U11 � TY <br /> ( ) ART ENT <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQ <br /> (i Jones Covey ro CHECK if BILLING ADDRESS <br /> C BUSINESS NAME • <br /> Jones Covey Group Inc. PHONE # 0-9300 EXT <br /> �a HOME or MAILING ADDRESS 5 Lucas Ranch Rd FAX # <br /> CITY ancho Cucamonga STATE CA ZIP 91730 <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 AL laws . <br /> APPLICANT'S SIGNATURE : DATED 5/6/2024 <br /> PROPERTY / BUSINESS OWNER 11OPERATOR / MANAGER OTHER AUTHORIZED AGENT IJ <br /> If APPLICANT 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it is provided t0 me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : S — 61 Q ' 0 <br /> COMMENTS : <br /> Replace existing TLS - 350 system with new TLS -450 plus monitoring <br /> system , replacing the MLLD with new digital PLLD and completing a cold start . <br /> ACCEPTED BY: \ ' EMPLOYEE #: DATE: GJ f <br /> ASSIGNED TO ; ` m � , EMPLOYEE #: DATE: <br /> Date Service Completed If already completed) : ERVICE CODE: lq 8 , 2q O PIE ' <br /> Fee AmountsAmount Paid / 62 , 06 Payment Date <br /> Payment Type VI Invoice # Check # g ' bzt �s�� Received By4F71 <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />