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SAN JOAQTPCOUNTY ENVIRONMENTAL HEALTHOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fuel Dispensing Facility A �(�� ��( 7 <br /> OWNER/OPERATOR <br /> Tesoro Refining&Marketing Company LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Tesoro site#68152 <br /> SITE ADDRESS 401 West Kettleman Lodi F9540 <br /> irection Street Name Ci Code <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 EXT• APN# LAND USE APPLICATION# <br /> ( 210 ) 626-6224 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> A&S Engineering/Ahmad Ghaderi CHECK If BILLING ADDRESS <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 (661 )250-9333 <br /> CITY Canyon Country STATE CA ZIP 91387 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned proper or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL ALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on th' form. <br /> I also certify that I have prepared this application and that t ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE aws. <br /> APPLICANT'S SIGNATURE: � 13 <br /> DATE <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER ❑ OTHER AUTHORIZED AGENT m Agent for Tesoro <br /> If APPLICANT is not the BILLING PA proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO ATION: 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: Plan Review for Turbine replacement. Replace existing MLLD's with new PLLD's for the UST's. <br /> COMMENTS: <br /> �h 'F�kpQj f <br /> onTV <br /> t Ili i <br /> "'AN '-JUN <br /> ,,,V:p oktItwt' <br /> ACCEPTED BY: EMPLOYEE#: D 4fjT, <br /> ASSIGNED TO: EMPLOYEE#: DATE: o <br /> Date Service Completed (if already completed): SERVICE CODE: 1066 P 1 E:J-�0 <br /> Fee Amount: Amount Paid �� ^ Payment Date (p /g/l L..' U <br /> Payment Type Invoice# Check#�/^ 4q,;,-7 Received By: L6 <br /> EHDREV SED 11/1 �D l SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />