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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 Retail Fuel Dispensing Facility to Remain >QD6 7 D�9V <br /> OWNER/OPERATOR CHECK if BILLING ADDRESSTesoro Refining&Marketing Company LLC <br /> FACILITY NAME <br /> Tesoro USA 68222 <br /> SITE ADDRESS 2132 E Mariposa Road Stockton, CA 95205 <br /> Street Number Direction Street Name city Zi.C.d. <br /> HOME or MAILING ADDRESS (if Different from Site Address) 19100 Ridgewood Parkway <br /> Street Number street Name <br /> CITY zip <br /> San Antonio STATE TX 78259 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION <br /> (210 ) 626-6224 �7'-O 100 5� <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> 1 11 00 1 11 01 <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR For this roject <br /> A&S Engineering,Ahmad Ghaderi,Agent for Tesoro CHECK if BILLING RIDDRESSO <br /> BUSINESS NAME PHONE# ExT. <br /> A&S Engineering,Ahmad Ghaderi ( 661 1 250-9300 <br /> HOME or MAILING ADDRESS FAx# <br /> 28405 Sand Canyon Road, Suite"B" 1 661 1 250-9300 <br /> CITY STATE zip <br /> Canyon Count[y. CA CA 91387 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENT HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified ENVIRONMENT <br /> s form. <br /> t 'TJ <br /> I also certify that I have prepared this application and[hat to be performed will be done in accordance with all SAN <br /> U hat t ork <br /> COUNTY Ordinance Codes,Standards,STATE and FLUE aws. AWrCqL-*. 1A1?- <br /> APPLICANT'S SIGNATURE: DATE: 11/13/2015 AID IVE6 <br /> - 11 2S -j,� <br /> �JOIq 4uri <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA GER ❑ OTHER AUTHORIZED AGENT®Agent for Te <br /> proof of authorization to sign is required Npvr <br /> If APPLICANT is not the BiLLiNG PAR proof 4*wg�,u <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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:Expedite Plan Review to obtain Permit for Proposed Upgrades/Modifications. <br /> COMMENTS: Remove All Existing Fill &Turbine Manways&Replace with OPW Fill &Turbine ManwayPAYMMIropw <br /> Fill Tubes With Overfill Protection. RECEIVED <br /> C—Xp,-CkL� 4L, NOV 18 2015 <br /> ,,,,N JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: scd a-A EMPLOYEE#: <br /> ASSIGNED TO: \10 EMPLOYEE#: DATE: II- JV-15- <br /> Date Service Completed (if already completed): I SERVICE CODE: I E a 30g- <br /> /?8, P <br /> Fee Amount: L)75y -2(,0 Payment Date (f <br /> Payment Type C 6D I Amount Paid C24 I /I <br /> Invoice# Cheek# 3 366Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />