Laserfiche WebLink
SAN JOAQU..- JOUNTY ENVIRONMENTAL HEALTH L—PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gas Station <br />F-9 �� c �jC <br />59- M% i-& <br />OWNER / OPERATOR <br />CHECK if BILLING <br />Tesoro Refining &Marketing Co., LLC <br />ADDRESS❑ <br />FACILITY NAME <br />Tesoro #68153 <br />SITE ADDRESS 2448 <br />W <br />Kettleman Ln. <br />Lodi <br />95242 <br />Street Number <br />Direction <br />Street Name <br />STATE CA <br />Cit <br />zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Date <br />Payment Type�/ <br />Street Number <br />Street Name <br />CITY STATE <br />ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECKif BILLINGADDRESSE] <br />Veronica Freitas <br />J4QU61?016 <br />BUSINESS NAME <br />^'i <br />44 <br />H rye,, MF� <br />PHONE # <br />ExT. <br />Walton Engineering, Inc. <br />(916)373-1166 <br />HOME or MAILING ADDRESS <br />DATE: �! / <br />FAX # <br />P.O. Box 1025 <br />DATE: <br />(916)373-1173 <br />CITY West Sacramento <br />STATE CA <br />zip 95620 <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: DATE: `3 )bQ I <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 13 Contractor <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 />t0 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. p <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />A/ 3 LJ <br />J4QU61?016 <br />^'i <br />44 <br />H rye,, MF� <br />ACCEPTED BY: C._ <br />EMPLOYEE #: <br />DATE: �! / <br />ASSIGNED TO: �` <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( C� <br />P I E: <br />Fee Amount: <br />Amount Amount Pai <br />3 L9o0 <br />Payment Date <br />Payment Type�/ <br />Invoice # <br />Check # 2/2267 <br />Rec ived By: D <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />