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SAN JOAQUIN-COUNTY ENVIRONMENTAL HEALT EPARTMENT SERVICE REQUEST Type of Business or Property Retail Fuel FACILITY ID # -FA 000 CHECK if BILLING ADDRESS❑ SERVICE REQUE T # OWNER/ OPERATOR PHONE# 91§ CHECK if BILLING ADDRESS FACILITY NAME CRLLC #2705448 #: W 3ffo DATE: FAX # ( 91Cy SITE ADDRESS 3202 Street Number W. Direction Hammer Lane Street Name ZIP 95691 Stockton CI 95209 21 Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Invoice # Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Dulcinea Covan - Compliance Manager 40p t�L CHECK if BILLING ADDRESS❑ BUSINESS NAME Walton Engineering, Inc. ACCEPTED BY: PHONE# 91§ EXT. 373-1166 HOME or MAILING ADDRESS P.O. Box 1025 #: W 3ffo DATE: FAX # ( 91Cy 373-1173 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: �— DATE: Li PROPERTY / BUSINESS OWNER❑ 1 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 6 Compliance Manager If APPLICANT is not the BILLING PARTY, proof of authorization t0 sigh 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 enviro ental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available amore time it is provided to me or my representative. "" ((((((t�//p /)'- TYPE OF SERVICE REQUESTED: U J—F O ll 40p t�L COMMENTS: I I �? 201 U 0 APR RM/AV �1q1r�/ SFS SAN JOAQUIN COUNTY ENVIRONMENT ACCEPTED BY: 4EMMPLOYEEPLOYEE#:P E !7ZZ0 ASSIGNED TO: . #: W 3ffo DATE: Date Service Completed (if already Completed): SERVICE CODE: / P 1 E: -2 Fee Amount: c� Amount Paid y S _ Payment Date41 q1b Payment Type Invoice # Check # 2- ✓l Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003