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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHR1laC3 i c� "' <br /> 1 LLLLLL......������ <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# b@WRA&ST# <br /> Retail Gas Dispensing Facility <br /> OWNER/OPERATORr-114 V In <br /> Colonial Energy, LLC DL D s❑ <br /> FACILITY NAME <br /> Colonial Enepy#40135 <br /> SITE ADDRESS 192Lathrop Rd. Lathrop 95330 <br /> Street Number Direction Street Name CI Zi 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 /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Angel ROdrlgUeZ 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA d FEDERAL laws <br /> APPLICANT'S SIGNATURE: � DATE:: 112-5117 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IN Pres:da <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 <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I 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 /> REVISED 11/17/2003 <br />