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NMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN�OUNTY ENVIRO <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Convenience Retailers, LLC./Pacific Conv. & Fuels CHECK If BILLING ADDRESS <br /> FACILITYNAME CRLLC #2705448 <br /> SITE ADDRESS 3202 West Hammer Lane Stockton 95209 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2603 Camino Ramon, Suite 350 <br /> Street Number Street Name <br /> CIN San Ramon STATE CA ZIP 94583 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (925) 884-0827 Q% Z5 2a (p <br /> —7 PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Michael Walton <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Walton Engineering, Inc. 916 373-1152 <br /> HOME Or MAILING ADDRESS Fax# <br /> P.O. BOX 1025 <br /> (916) 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,ST <br /> 02-16-11 <br /> APPLICANT'S SIGNATURE - DATE: <br /> : <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 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: ✓1 T <br /> MEN I <br /> COMMENTS: Repair failed 87 direct bury spill bucket F' <br /> FFGFIVED <br /> FEB 16 2011 <br /> SAN!OACUIN COUN7'f <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: W EMPLOYEE#: �63/ DATE: <br /> to v <br /> ASSIGNED TO: EMPLOYEE#: T 6 DATE: J <br /> T G <br /> Date Service Comple (if already completed): SERVICE CODE: TP/E: Za <br /> Fee Amount: b Amount Paid 3 b(o Payment Date z J(b 1 1 <br /> Payment Type. Invoice# =ewk <br /> # Received By: C' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />