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r7� <br />SAN JOAQUW CouNTY EwRONM.ENTAL HEALTH DErARTmF, <br />SERVICE REQUEST ENV1RCPV;'AEN TA!_ HFAi Tm <br />Type of Business or Property <br />FACILITY 10 # 8E61f ES <br />Fuel Dispensing Facility <br />(� (�% {1p0 -)–J <br />OwaaR / OPERATOR <br />13 <br />Tesoro Refining & Marketing Company LLC <br />cNEcc�KeluaNta ADoaaas <br />FAaLmr NAME Tesoro site # 68152 <br />iCNYlJ("1)UINT <br />SITEAQDwos 401 Whet Kettleman <br />Lodl 95240 <br />HOME or MAIUN® Auiltess (If DiKarent from site Addreee► <br />18100 Ridgewood Parkway <br />HOME or MAIUNO ADDREss <br />Sebe <br />CITY San Antonio <br />wase TX ZIP 78259 <br />PHONE #1 E0• <br />APN 0 <br />( §61250-9333 <br />LAND UK AppucATM 1 <br />( 210 D 626-6224 <br />STATE CA <br />ZIP 91$87 <br />Check # 4q ,o .1 <br />PHONE N2 <br />DISTRICT <br />L®Ca7lON CDOa <br />► <br />00 <br />Q <br />REQUESTORSir <br />Plan Review for Turbine replacement. Replace exisfing MLLD's with new PLLD's for the UST's. <br />COYMSNrs: <br />A& S Englneering/ Ahmad Ghaderi <br />CHECK 14 <br />BUatNEse NAME A & S E nglneeHng <br />BAN J0A <br />p"OWy <br />iCNYlJ("1)UINT <br />ACcePTeo BY: <br />EMPLOYER <br />661 <br />250-9300 <br />HOME or MAIUNO ADDREss <br />DALE: 1 Q' <br />FAX N <br />l—mody complotod): SERVICE CODE! (� <br />28405 Sand Canyon Road Sults B <br />Fee Amount: ka <br />( §61250-9333 <br />Payment Date I t> h gl la <br />CITY Canyon Country <br />STATE CA <br />ZIP 91$87 <br />BI1<.1•,1NG ACKNOWILEDgEMEN'C: 1, the undersigned proper oL• business owner, operator or aatborbwd agent of game, <br />acknowledge that all site and/or project specific ENVIRONMENTAL LTu DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identZonform. <br />t also certify that ( have prepared this application and to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Or dbrance Codes, Standards, STATP_ and FED <br />APPLICANT'SSTCNATURE: DATE: to/I 0 t <br />PROPERTY I IRUSINFNS OWNER❑ Orgra \Toil/ AGER ❑ Ormzs; AUTHQKiz D AcEN,r Agent for Tesoro <br />IfAPPL/CaNr Is not dive AUJ&9 PA proefof amehor/2alion to sign Is required TWO <br />N 3M.ELLYWE INFOR AT N: When applicable, 1, the owner or operatnr of the property located at the <br />above site address, hereby authorize the release of any and ail mulls, 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 flims it Is <br />provided to me or my representative. <br />TYPFoF SERVICE REQUESTED: <br />Plan Review for Turbine replacement. Replace exisfing MLLD's with new PLLD's for the UST's. <br />COYMSNrs: <br />:L <br />ow I V E <br />BAN J0A <br />iCNYlJ("1)UINT <br />ACcePTeo BY: <br />EMPLOYER <br />DAIC-164 <br />ASSIoNED To;�—eA <br />(EMPLOYEE #: <br />DALE: 1 Q' <br />Date Service Completed (I <br />l—mody complotod): SERVICE CODE! (� <br />P 1 E: JWY <br />Fee Amount: ka <br />Amount Paid � 55 ^ <br />Payment Date I t> h gl la <br />Payment Type 1/ <br />invoice IK <br />Check # 4q ,o .1 <br />Received By: i6 <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Received Time Apr.13. 2017 2:30PM No,1250 <br />SR FORM (Golden Rod) <br />