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SAN JOAQUIN*NTY ENVIRONMENTAL HEALTH I&ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SER(VI,CE-7REQU�ESI T# <br /> Gas Station Ems© 55 ()" / �✓"�C� <br /> OWNER/OPERATOR <br /> Tesoro Refinging&Marketing Co. LLC CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Tesoro # 9 150 <br /> SITE ADDRESS 13975 E. Hwy 88 Lockeford 95237 <br /> Street Number Direction Street Name city Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 19100 19100 Ridgewood Pkwy <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> San Antonio TX 78259 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Veronica Freitas CHECK If BILLING ADDRESS FRI <br /> BUSINESS NAME PHONE# EXT. <br /> Walton Engineering, Inc. 916 373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 (9 ) 373-1171 <br /> CITY West Sacramento STATE CA 95691 <br /> ZIP <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I 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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 10/06/17 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® 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 <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: (A SST �-'t ri rZ ka L. 1 4 <br /> COMMENTS: RECEIVED 1 r T1 2017 <br /> OCT 0 9 2017 4FALTH <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: r 14 `' EMPLOYEE M ?/� DATE: <br /> ASSIGNED TO: a l o EMPLOYEE M 5 DATE: <br /> Date Service Completed (if already c pieted): SERVICE CODE: lap / PIE: ? 8 <br /> Fee Amount: 4P [�q Amount Paid Payment Date <br /> Payment Type Invoice# Check# 5 oZ 7 O Received By:� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />