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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 -,5Rf673Ice--go <br /> OWNER/OPERATOR <br /> Tesoro Refining&Marketing Company LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Tesoro USA 68222 <br /> SITE ADDRESS 2132 E Mariposa Road Stockton, CA 95205 <br /> Street Number Direction Street Name CI zip ceEe <br /> HOME or MAILING ADDRESS (If Different from Site Address) 19100 Ridgewood Parkway <br /> Street Number street Name <br /> CITY San Antonio STATE TX Zip 78259 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (210 ) 626-6224 <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR For this�roject <br /> A&S Engineering,Ahmad Ghaderi,Agent for Tesoro CHECK If BILLING ODRESS <br /> El <br /> BUSINESS NAME PNE# ExT. <br /> A&S Engineering,Ahmad Ghaderi 6HO611 250-9300 <br /> HOME or MAILING ADDRESS FAX# <br /> 28405 Sand Canyon Road Suite"B" ( 661 ) 250-9300 <br /> CITY - STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or auth D <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 on is fornT. NOV 2 5 2015 <br /> I also certify that i have prepared this application and that work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FED E laws. ENVIRONMENTAL HEALTH <br /> APPLICANT'S SIGNATURE: DATE:11/13/2015 PERMIT/SERVICES <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER 11 OTHER AUTHORizEn AGENT®Agent for Tesoro <br /> If APPLICANT is not the BILLING PAA Y,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 environmental/site 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 Manways. Install r4ew DPW <br /> Fill Tubes With Overfill Protection. <br /> ACCEPTED BY: EMPLOYEE#: DATE: I <br /> ASSIGNED TO: --OASA V O EMPLOYEE#: DATE: <br /> Date Service Completed (if aliddy completed): SERVICE CODE: PIE: <br /> Fee Amount: 'J�1� ' 00 Amount Paid Payment Date <br /> Payment Type Invoice# g7.2.`T ' Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />