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SAN JOAQUINNT.1 ENVIRONMENTAL HEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Retail Fuel �j � S tz 005"INg-3 <br /> OWNER/OPERATOR <br /> Quik Stop Market, Inc . CHECK if BILLING ADDRESS❑ <br /> FACILITY NAI! <br /> Stop #124 <br /> SITE ATRS N Main Street FManteca 95336 <br /> Street Number I Direction I Street Name CI 7ZIPCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 519 657-8500 Z( 7 - 2('0 <br /> PHONE#1 EXT. BOS DISTRICT LOCATI N CODE <br /> ( 1 .3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dulcinea Webb CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Walton Engineering, Inc . P 373-1166 ExT. <br /> HOME or MAILING ADDRESS Fax# <br /> P.O. Box 1025 016 ) 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,Standard's, <br /> -ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> Compliance <br /> (CD `A-�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT[; Com1 i anc a Manager <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: (t-s- <br /> COMMENTS: <br /> sCOMMENTS: <br /> DD <br /> JUN 0 5 2009 <br /> EWRJN", ENT HEALTFI <br /> ACCEPTED BY: O L-t EMPLOYEE M f„ 0 DA <br /> ASSIGNED TO: 0 C L I-If— EMPLOYEE#: Z, DATE: S 0 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: (� Amount Paid Payment Date le S <br /> Payment Type Invoice# Check# Lt(3S"� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />