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T <br /> SAN JOAQU.- :OUNTY ENVIRONMENTAL HEALTh e PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel ( �� 31e-00 3 7 L? <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Cruisers Manteca (BP #29) <br /> SITE ADDRESS 1137 W Lathrop Road Manteca 95336 <br /> Street Number Direction 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#'I ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Covan - Compliance Manager CHECK if BILLING ADDRESS <br /> BUSINESS NAME Walton Engineering, Inc . PHONE# ExT. <br /> 91 373-1166 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 1025 ( 91C 373-1173 <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: ��__ �_ DATE: �U (.,- �,\ <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Compliance Manager <br /> If ADPL/CANT is not the BILL/NG 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 /> � 2� 201 <br /> SP�Nv RUM NME�'�EP1T <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: ( 0 <br /> ASSIGNED TO _-t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C- P 1 E:-2 C�8 <br /> Fee Amount: O �0 Amount Paid 3'7s v D Payment Date (p <br /> Payment TypeLIZ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />