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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST .� <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> Retail Fuel <br /> OWNER/OPERATOR / FJ <br /> Circle K Stores, Inc . CHECKIf BILLING ADDRESS❑ <br /> FACILITY NAME Circle K #2701205 <br /> SITE ADDRESS 16470 Cambridge Drive Lathrop 95330 <br /> Street Number I DirwIlm I Street Name CRY Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stree!Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c(30-32--- <br /> PHONE#2 Ex . BOS DISTRICT 7 LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Walton Engineering, Inc . PHggt 373-1166 Fm <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( 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 JoAQu[N <br /> CouNTY Ordinance Codes,Standards,STATE and FEDERAL laws. L� � <br /> APPLICANT'S SIGNATURE: DATE:: \- -JJ0•CD <br /> PROPERTY/BuSDNEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Q Compliance Manager <br /> IfAPPLteANT 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 army Ips same time it is <br /> provided to me or my representative. �} l�i v <br /> TYPE OF SERVICE REQUESTED: tt 7 fi -G.' -lt IC ( AAA 1 ECEIVED <br /> COMMENTS: <br /> ENVIRONMENT H96H 1 2009 <br /> PERMIT/SERVO;,OAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 6C C-C L)E( EMPLOYEE M O 3 DATE: Jr O <br /> ASSIGNED TO: /tc-NQ #:EMPLOYEEI'6 y� DATE: S, v p <br /> Date Service Completed (if al ady completed): SERVICE CODE: QdJ. P 1 E:.z-3 Da <br /> Fee Amount: Amount Paid sg Payment Date <br /> Payment Type Invoice# Check# Received By: - (_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />