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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Existing Gas Station U � S Ra Al OW 'a a OWNER / OPERATOR Western Refining Retail LLC CHECK if BILLING ADDRESS ❑ FACILITY NAME Tesoro ( Speedway) #68154 SITE ADDRESS 2500 W Lodi Ave Lodi 95242 Street Number Direction Street Name CIty Zio Code HOME or MAILING ADDRESS (If Different from Site Address ) P . O Box 711 Attn : Gasoline Compliance , LOC 148 street Number Street Name CITY Dallas , TX 75221 STATE ZIP PHONE #1 EXT• APN # LAND USE APPLICATION # ( 661 ) 250 -9300 PHONE #2 EXT• BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTO ' (l REQUESTOR ) Ones Covey Group Inc . CHECK if BILLING ADDRESS Exr. + k BUSINESs NAME Jones Covey Group Inc . PHONE # ( 661 ) 250 -9300 HOME or MAILING ADDRESS 9595 Lucas ch Rd CITY Rancho Cucamon STATE CA ZIP 917 BILLING A LEDGEMENT : I , the undersigned property or business owner, operator or authorized agent o same , acknoW e that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDER L laws . APPLICANT'S SIGNATURE : DATE : 5/7/2024 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER OTHER AUTHORIZED AGENT LrJ If APPLICANT is not the BILLING PARTY, (hoof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable, I , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it is provided to me or my representative . TYPE OF SERVICE REQUESTED : usi Rarofil T COMMENTS : NN Replace existing TLS - 350 system with new TLS -450 plus monitoring RECEIVED system , replacing the MLLD with new digital PLLD and completing a cold start .-JUN 10 2024 = SAN JOAQUIN COUNTY NVIRONM NTAL ACCEPTED BY: Q J�J� /� EMPLOYEE # : DATE : I DEPARTMENT ASSIGNED TO : y i w0 I d e � A EMPLOYEE # : DATE: Date Service Completed (if already completed) : - SERVICE CODE: I E' /f ij Fee Amount 2— Amount Paid Payment Date 6 V 2--1 Payment Type Invoice # Cjh c # J 2 O 6 ( Received By: EHD 48-02-025 g � SR FORM (Golden Rod ) 07/ 17/08