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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACII1JT/YIDID,I SERVICE REQUEST# <br /> Existing to remain retail fuel dispensing facility om <br /> OWNER/OPERATOR <br /> Tesoro Sierra Properties LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Store#4612 <br /> SITE ADDRESS 2448W Kettleman Lane Lodi 95242 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 19100 Ridgewood Parkway <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> San Antonio TX 78259 <br /> PHONE#1 For this project Ex . APN# LAND USE APPLICATION# <br /> ( 661 1 250-9333 058-140-01 <br /> PHONE#2 Ei. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> A&S Engineering CHECK If BILLING ADDRESS <br /> BUSINESS NAME A&S Engineering PHONE# En' <br /> 661 250-9333 <br /> HOME or MAILING ADDRESS FAx# <br /> 28405 Sand Canyon Rd Suite B I ( ) <br /> CITY Canyon Country <br /> STATE CA ZIP 91387 <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, STATE and FEDER L laws. <br /> APPLICANT'S SIGNATURE: DATE: 7/30/2019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER lij OTHER AUTHORIZED AGENT® Authorized Agent <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 proper QI,, ted at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environment�_ck <br /> Information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: r1 <br /> ft <br /> COMMENTS: V <br /> yF C �''NM COIN <br /> ACCEPTED BY: EMPLOYEE#: 2—e3 DATE: <br /> ASSIGNED TO: t EMPLOYEE#: /0G DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> \\ 5 PIE: <br /> Fee Amount: �,S` Amount PaI l)d Payment Date - <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />