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SAN JOAQIWOUNTY ENVIkONMENTAL HEAL110PARTMENT SERVICE REQUEST Type of Business or Property YJ (7 FACILITY ID # SERVICE REQUEST # ACCEPTED BY:®L . ✓ i EMPLOYEE #: DATE: 1� Z / OWNER/ OPERATOR CHECK if BILLING ADDRESS❑ Quik Stop Markets, Inc. Date Service Completed (if already Completed): FACILITY NAME Quik Stop # 132 SITE ADDRESS 3555 West Hammer Lane Stockton `JS'21q Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 4567 Enterprise Street Street Number Street Name CITY STATE Zip Fremont CA 94538 PHONE #1 EXT• APN # LAND USE APPLICATION # ( 510) 657-8500 PHONE #2 EXT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS14 BUSINESS NAME, PHONE # Exr. Walton Engineering, I n�' ' r 916 373-1165 HOME or MAILING ADDRESS / FAX # P.O. Box 1025 2 4U10 (916)373-1173 CIN West Sacramento , r , TATE CA Zip 95691 BILLING ACKNOWLEDGEMENT: I, the undersigneppi ta owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTALEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STA aIn/d FEDERAL laws. APPLICANT'S SIGNATURE: J/ �i� S l f�� DATE: 2,3 ' h PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IYi- If APPLlcANT is not the BiLmNG PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site0 en information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the samq`t,. provided to me or my representative. ��/F6 TYPE OF SERVICE REQUESTED: (�( YJ (7 bAn; COMMENTS: This facility is upgrading its POS equipment. This requirl1�kR NMFc� DFp� � monitoring system "cold -start" to ensure proper communication. A Monitoring System Certification will be performed and submitted to the Owner and the Agency (including alarm history). ACCEPTED BY:®L . ✓ i EMPLOYEE #: DATE: 1� Z / ASSIGNED TO: A c- z -CS EMPLOYEE #: [l(- 47 b DATE: F- 41a Date Service Completed (if already Completed): SERVICE CODE: ©e PIE: 2-C� 00 Fee Amount: �.� Amount Paid PaymentDate'a Payment Type Invoice # Check # LJ 3 U 9 Received By: GyZ, EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 M V7y Vr