Laserfiche WebLink
0 . . 0 <br />RECEIVED dS <br />SAN JoAQvm COUNTY ENVIRONMENTAL HFALTIH[ AEJPARTME <br />�.00 R 1 3 201 <br />r <br />Type of Buslne4 a or Property <br />FACUTY 104 SEv-S, <br />Fuel Dispensing Facility <br />A& S Engineering/ Ahmad Ghaderi <br />OWMiR / OPERATOR <br />ClteracIf Ithwto Alluma <br />Tesoro Refining & Marketing Company LLC <br />CWCKifHtuatoADORsas <br />FAcolmr NAME Tesoro site # 68152 <br />Es• <br />SITEAoDws 401 <br />11MRINHWIRL, <br />West <br />.2kardW2 <br />I Kettleman <br />250-9300 <br />Dodi <br />ream <br />95240 <br />All E21111 <br />Home or WuNe ADaRess (It Dh1krent tram sate Address) <br />19100 T Ridgewood Parkway <br />28405 Sand Canyon Road Sulfe 9 <br />Bing nn,M <br />CIn San Antonio <br />STATE TX zip 78259 <br />PRONE #1 a <br />APN R <br />LAND Use APPucATIW ti <br />( 210 ) 626-6224 <br />PHONE 02 ate' <br />006 DISTRICT <br />LocAnoN Coos <br />00 <br />4 <br />CONTRACTORSERVICEREQUESTOR <br />E®UWOR <br />Plan Review for Turbine replacement_ Replla�ce existing MLLD's with now PLLD's for the UST's. <br />CoattEnrrs: <br />A& S Engineering/ Ahmad Ghaderi <br />AccePTEo BY: <br />ClteracIf Ithwto Alluma <br />BUSINI'.99 NAME A & S E <br />Engineering <br />DA* 1 t4 <br />PRONE s <br />Es• <br />EMPLOYEE #: <br />DATE: , Q, <br />661 <br />250-9300 <br />Home or Mmuma ADDRESS <br />P / E. (7+ <br />D <br />FAx 0 <br />28405 Sand Canyon Road Sulfe 9 <br />Payment Date I p I gh (o <br />( <br />)250-9333 <br />CITY Canyon Country <br />sTA CA <br />ZIP 91387 <br />HIULING ACKNOWLEDGENENT: 1, the undcrsigned proper or business owner, operator or aatborUed agent of same, <br />acknowledge that all site and/or project specific Ir1QVIRONMENTAt LTTI DEPARTMENT hourly charges associated with this project <br />or activity will be billed tome or my business as identified on th' form. <br />1 also eertitj+ that ( have prepared this application and that tl ork to he performed will be done in accordance with all SAN JOAQtma <br />COUNTY Ondbrance Codes, Sfancfards, STATE and FEDER. aws. <br />AP"PLICANT"S SIGNATURE: DAA: 10/1 ® ` <br />PaopE;my / RusmFss OWNER❑ OPERATOR ICER ❑ 01TtER AUTHORIZEt► ACEN7 Agent for Tesoro <br />If APPLICANT is not altaA Proof Of amehorlaarlon to sign is required rifts <br />N A E INFOR AT N: When applicable, 1, the owner or operator of the property toeatcd at the <br />above mite address, hereby authorize the release of any and ail t'esults, geotechnical data and/or environmental/site assessment <br />information to the SAN 10AQtnN (-01P4Tv ENvtRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the seine Vine It Is <br />provided to me of my representative. <br />TypeoFSERVICE REtal1ESTED: <br />Plan Review for Turbine replacement_ Replla�ce existing MLLD's with now PLLD's for the UST's. <br />CoattEnrrs: <br />i�.�v=T F�I� ��1 v�-��.. '- [ ,JC/ t• U. <br />r-a� <br />OCT tri 2u�s <br />,I0? i aun1l_nr i n ,`" t <br />30 61 <br />AccePTEo BY: <br />EMPLOYEE #: <br />DA* 1 t4 <br />ASST D To: � <br />EMPLOYEE #: <br />DATE: , Q, <br />Date Service Completed ( <br />mady completed): <br />SERWM Gone: <br />P / E. (7+ <br />D <br />Fee Amount: <br />Amount Paid <br />Payment Date I p I gh (o <br />Payment Type j/ <br />Invoice # Check # L f Gp �.7 <br />Received By: <br />EHD 48-02-025 <br />REVISED 11!17/2003 <br />Received Time Ap03. 2017 2:30PM No.1250 <br />SR FORM (Golden Rod) <br />