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RECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JAN 2 9 2018 <br /> SERVICE REQUEST I:NVIRON;IIF.NTAL HEALTH <br /> Type of Business or Property FACILITY ID# SERVICE REQ V.4 RTINI NT <br /> Retail Gas Dispensing Facility `J�ooi310g1 <br /> OWNER/OPERATOR <br /> Colonial Energy, LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Colonial Energy#40135 <br /> SITE ADDRESS 192 Lathrop Rd. Lathrop 95330 <br /> Stree[Number pirecaon Stree[Name Ci 2i Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SVeat NumOer Street Name <br /> CITY STATE zip <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> I ) I 1 9(01-3w 1 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) 003 U <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Angel Rodriguez CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Exc <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 force, <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,STAly- d FEDERAL laws / �^, <br /> APPLICANT'S SIGNATURE: A Y I �-�I DATE: 1/2-5 / I 0 <br /> q <br /> PROPERTY/BUSINESSOWINER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® prF.S: jO'4' <br /> IfAPPLfCANT is not the BILL/NG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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�� .e and at the same time it is <br /> provided to me or my representative. M c <br /> TYPE OF SERVICE REQUESTED: US CI D <br /> COMMENTS: <br /> JAN ?9 ?018 <br /> a%"OAQUIroC <br /> Helvw&rpME A <br /> ACCEPTED BY: - r EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ICI V PIE: 23p� <br /> FeeAmount: <br /> k..+ sla 49�) Payment Date <br /> Payment Type C Invoice# Check# 53��3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �& <br />