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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Gas Dispensing Facility j� � <br /> OWNER / OPERATOR <br /> Tesoro #68154 CHECK if BILLINGADDRESSE] <br /> FACILITY NAME <br /> Tesoro #68154 <br /> SITE ADDRESS c+ a . ., l .a .. „ �- n� •t <br /> 2500 W . Lodi Ave -�,- 95242 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Michael Walton CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT . <br /> Walton Engineering , Inc . 916 373- 1165 <br /> HOME Or MAILING ADDRESS P . O . Box 1025 FAx <br /> 916 ) 373 - 1172 <br /> CITY West Sacramento STATE CA zIP 95691 <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 nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE an EDERAL laws . <br /> APPLICANT'S SIGNATURE : DATE : <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sigh 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 . p <br /> TYPE OF SERVICE REQUESTED : I gq <br /> COMMENTS : <br /> `` 0 2018 <br /> y CNV/RENIN COUN <br /> �ALTy p��M NT <br /> ACCEPTED BY: n , ^ EMPLOYEE #: q DATE : <br /> ASSIGNED TO : S0./ EMPLOYEE #: I DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE : l $ P / E : <br /> Fee Amount : Amount Paid 4e & , O v Payment Date <br /> Payment Type ,/ Invoice # Check # 5tf37Z Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />