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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID(#�/ pSERVICE REQUEST# <br /> Fuel Dispensing Facility1 D GJI— kto-bte <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS E] <br /> Tesoro Refining& Marketing Company LLC <br /> FACIDTY NAME Tesoro site#68222 <br /> SITE ADDRESS 2132 1 East Mariposa Stockton 95205 <br /> Street Number Direction I Street Name CIW 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 19100 Ridgewood Parkway <br /> Street Number S[reet Name <br /> CITY San Antonio STATE TX ZIP 78259 <br /> PHONE#1 En. APN# ' ^ LAND USE APPLICATION# <br /> ( 210 1626-6224 1Le03� <br /> PHONE#2 Exr. SOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> A&S Engineering/Ahmad Ghaderi CHECK If BILDNG ADDRESS <br /> BUSINESS NAME PHONE# Em. <br /> A&S Engineering 9 9 661 250-9300 <br /> HOME or MAILING ADDRESS FAX# <br /> 28405 Sand Canyon Road Suite B 1 (661 )250-9333 <br /> CITY Canyon Country 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 ENVIRONNYNTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as idon this form. <br /> I also certify that I have prepared this application and/he work to be performed will be done in accordance with all SAN]oAQtmN <br /> COUNTY Ordinance Codes,Standards,STATE and F laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESSOWNER❑ OPE R/MANAGER ❑ OTHER AUTHORIZED AGENTS AgentforTesoro <br /> JfAPPLICANT is not the B/L . G PARTY proof of authorization to sign is required rule <br /> AUTHORIZATION TO RELEASE ORMATION: 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 JO.AQUIN 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 /> TYPEOF SERVICE REQUESTED: Plan Review for Turbine replacement. Replace existing MLLD's with new PLLD's for the UST's. <br /> COMMENTS: <br /> RECEIVED <br /> OCT 1 S 2016 <br /> N COUNTY <br /> ACCEPTED BY: EMPLOYEE#: DATELtV N <br /> MENT <br /> ASSIGNED TO: EMPLOYEE#: ATE:lo-I y-1 o <br /> Date Service Completed (N already Completed): SERVICE CODE: PIE: VJ <br /> Fee Amount: tarocv Amount Paid G 2S Payment Date 0 <br /> Payment Type Invoice# Check# [¢Cl2-7 Received By: (� <br /> EHD 48-02-025 �/ � . SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />