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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTROPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> Christina Gill <br /> FACILIIYds tE Lane Lathrop <br /> SITE ADDRESS 116 E. Roth Road Lathrop 953ZI30 <br /> Street N"m r Direction treat Name CI C e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Numlror Street Name <br /> CITY STATE ZIP <br /> PHONE#t En. APN# LAND USE APPLICATION# <br /> ( 707) 326-0369 <br /> PHONEtrt En. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb CHECK If BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering, 2 P�� 373-1166 EXT. <br /> HOME Or MAILING ADDRESSFAX# <br /> P.O. Box 1025 DIC 3 0 2009 016 ) 373-1173 <br /> CITY West Sacramento ENVIRONIVIENTHEAJDATE CA ZIP 95691 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned PP4 rwr�bmv"Swner, 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,Stan SAETTand FEDERAL l�wso- �1 4 <br /> APPLICANT'S SIGNATU lA �./X� DATE: \0 <br /> PROPERTY/BUSINESS OR'NER❑ OPERATOR/MANAGER ❑ OTHER AUTHORMDAGENT[; Compliance Manager <br /> IfAPPLrCvvT is not the BILLnVG 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 available and at the same time it is <br /> provided to me or my representative. f <br /> TYPE OF SERVICE REQUESTED: ( ECEIV E <br /> COMMENTS: �D^ � 0 ZOOS <br /> l� f 975TP , U �� SBnSor and aksas o• DEC 3 <br /> SA ENVIRONME TMALENT <br /> HF�-TN DEPAR <br /> ACCEPTED BY: EMPLOYEE#: q/u DATE: ( a -3 0-4 <br /> ASSIGNEDTO: EMPLOYEE 5L4 DATE: 30-0 <br /> Date Service Completed (if already completed): SERVICE CODE: CC PIE: 2 <br /> Fee Amount: l O Amount Paid Payment Date \2136JOI <br /> Payment Type Invoice# Check# L� 2�'� \ Received By: IN'& <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />