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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 <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 Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P . O Box 711 Attn : Gasoline Compliance , LOC 148 =Number Street Name <br /> CITY Dallas , TX 75221 STATE ZIP <br /> PHONE #'I ExT. APN # LAND USE APPLICATION # <br /> ( 661 ) 250-9300 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRES <br /> Ir <br /> A & S Engineering <br /> Droll <br /> BUSINESS NAME PHONE # ExT. <br /> A & S Engineering (661 ) 250 - 9300 <br /> HOME or MAILING ADDRESS FAX # <br /> 28405 Sand Canyon Road , Suite " B " ( ) <br /> ITY 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 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 FEDERAL laws. <br /> APPLICANT' S SIGNATURE : DATEa 7/ 16/2024 <br /> PROPERTY / BUSINESS OWNER 0 OPE OR / MANAGER ❑ OTHER THORIZED AGENT L:I <br /> If APPLICANT 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 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 to me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <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 : <br /> ASSIGNED TO : EMPLOYEE #: DATE, <br /> Date Service Completed (if already completed) : SERVICE CODE: P 1 E : <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />