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SAN JOAQu ,COUNTY ENVIRONMENTAL HEALTk.-DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel 1 D7 SR DO <br /> OWNER/OPERATOR <br /> Circle K Stores, Inc. CHECK If BILLING ADDRESS❑ <br /> Rcii`Vrcle K #2701205 <br /> SITE ADDRESS 16470 Cambridge Drive Lathrop 95330 <br /> Street Number I orcUmn Street Name City Zip 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 /> PHONE 92 En. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Covan <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME P EXT' <br /> Walton Engineering, INC . 373-1166 <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C-"nr� �� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENTff Compliance Manager <br /> IJfAPPL/CANT 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 JOAQUDN 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 /> RECEIVED <br /> FEB 16 2011 <br /> SAN JOAQUIN COJNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: TU EMPLOYEE#. 075-3 <br /> 't7(3 DATE: / /_ I/ <br /> ASSIGNEDTO: EMPLOYEE#: J DATE: 02= )/lab /' <br /> 'a y <br /> Date Service Completed (If already completed): SERVICE CODE: PIE:230g <br /> Fee Amount: ,U O Amount Paid b Payment Date I b <br /> Payment Type �� Invoice# Check# o Receive By: V& <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />