Laserfiche WebLink
SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Fuel Dispensing Facility <br />iA�(�^� <br />( 7 <br />OWNER/ OPERATOR <br />CHECK if BILLING <br />Tesoro Refining & Marketing Company LLC <br />ADDRESS❑ <br />FACILITY NAME <br />HUME:NTrOUIN <br />Tesoro site # 68152 <br />250-9300 <br />SITE ADDRESS 401 <br />West <br />Kettleman <br />DATE: c>„ "6- <br />Lodi -T <br />95240 <br />Street Number <br />Direction <br />CITY Canyon Country <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />19100 <br />Ridgewood Parkway <br />Received By: NJ <br />Street Number <br />Street Name <br />CITY San Antonio <br />STATE TX Zip 78259 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 210 ) 626-6224 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />00 11 <br />01;� <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Plan Review for Turbine replacement. Replace existing MLLD's with new PLLD's for the UST's. <br />COMMENTS: <br />A & S Engineering/ Ahmad Ghaderi <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />A & S Engineering <br />OCA 1 8 2016 <br />PHONE# <br />EXT. <br />HUME:NTrOUIN <br />661 <br />250-9300 <br />HOME or MAILING ADDRESS <br />FAX # <br />DATE: c>„ "6- <br />28405 Sand Canyon Road Suite B <br />SERVICE CODE: U <br />( 661 <br />)250-9333 <br />CITY Canyon Country <br />STATE CA <br />ZIP 91387 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned propertl or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAALTH 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 oro <br />COUNTY Ordinance Codes, Standards, STATE and FEDERNFaWS. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ 1\ AGER ❑ <br />to be performed will be done in accordance with all SAN JOAQUIN <br />DATE: 10/13/-17.01,6 <br />OTHER AUTHORIZED AGENTS( Agent for Tesoro <br />/f APPLICANT is not the BILLING PARtY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFOR 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: <br />Plan Review for Turbine replacement. Replace existing MLLD's with new PLLD's for the UST's. <br />COMMENTS: <br />L �� <br />Ch A j �p <br />D <br />I!F E <br />OCA 1 8 2016 <br />UN <br />5ANICV <br />HUME:NTrOUIN <br />ACCEPTED BY:'IamEMPLOYEE <br />#: DWA�. <br />1)0 <br />ASSIGNED TO: —&qrkQ <br />EMPLOYEE #: <br />DATE: c>„ "6- <br />D <br />Date Service Completed (if already completed): <br />SERVICE CODE: U <br />P / E: <br />Fee Amount: Lp-)Amount <br />Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 4q,;,-7 <br />Received By: NJ <br />EHD SED 11/1 I �D � SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />