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SAN JOAQUII LINTY -ENVIRONMENTAL HEALTI�PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Retail Fuel 2009 OWNER/ OPERATOR CHECK if BILLING ADDRESS❑ Quik Stop Market, Inc. FAX # FACILITYNAME Quik Stop #132 N TH p'4 -a AL Y SITE ADDRESS CITY West Sacramento STATE CA ZIP 95691 ACCEPTED BY: EMPLOYEE #: DATE: 3555 Street Number Direction Hammer Lar et Name Stockt� a 21,5c2 019 HOME or MAILING ADDRESS (If Different from Site Address) PIE: 23� Fee Amount: 7�.� "0Amount Paid 3�5 U Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( 510) 657-8500 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR rn Dul c i ne a Webb CHECK if BILLING ADDRESS BUSINESS NAME Walton Engineering, Inc. 2009 PIR ff 1166 EXT. HOME or MAILING ADDRESS SQN SCA ENVI QUIN COU FAX # P.O. Box 1025 N TH p'4 -a AL Y (916)373-1172 CITY West Sacramento STATE CA ZIP 95691 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL, HEALTH 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, STATE and FEDERAL. laws. APPLICANT'S SIGNATURE:_--- �yY, DATE: 0 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Compliance Manager If APPLICANT is not the BILLING 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/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PAS PAIi "— TYPE OF SERVICE REQUESTED: (J9T f� �I vf� b COMMENTS:1 2009 SQN SCA ENVI QUIN COU N TH p'4 -a AL Y ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: FAa-EMPLOYEE #: Tl DATE: Date Service Completed (if already completed): SERVICE CODE: 10D PIE: 23� Fee Amount: 7�.� "0Amount Paid 3�5 U Payment Date 41 1 Payment Type ✓ Invoice # Check # 4ocigg Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003