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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Existing Gas Station <br /> OWNER / OPERATOR <br /> Western Refining Retail LLC CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME Tesoro ( Speedway) #68154 <br /> SITE ADDRESS 2500 W Lodi Ave Lodi 95242 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P . O Box 711 Attn : Gasoline Compliance , LOC 148 Street Number Street Name <br /> CITY Dallas , TX 75221 STATE Zip <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 661 ) 250-9300 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> A & S Engineering Tor this prok <br /> BUSINESS NAME PHONE # EXT. <br /> A & S Engineering661 ) 250-9300 <br /> HOME or MAILING ADDRESS FAX # <br /> 28405 Sand Canyon Road , Suite " B " ( ) <br /> PITY STATE CA ZIP 91387 <br /> Canyon Counti3j <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 or <br /> 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 FEDERAL laws . <br /> APPLICANT' S SIGNATURE : DATE. 7/ 16/2024 <br /> PROPERTY / BUSINESS OWNER ❑ PERATOR / MANAGER ❑ 07 ER AUTHORIZED AGENT IJ <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> 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 <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> Replace existing TLS - 350 system with new TLS -450 plus monitoring <br /> system , replacing the MLLD with new digital PLLD and completing a cold start . <br /> ACCEPTED BY: EMPLOYEE #: DATE : <br /> ASSIGNED TO : EMPLOYEE #: DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE : P / E : <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />